CDI Risk Higher for People with COVID-19

A new report looking at hospital-acquired Clostridioides difficile infection (CDI) rates among people with and without COVID-19 found that the CDI incidence rate among people infected with SARS-CoV-2 was much higher than the incidence rate among people not infected with the virus.

However, the investigators also concluded that the increased risk was likely tied to the use of antibiotics and other therapies, rather than due to changes in infection control procedures. The study was published in the journal Microorganisms.

Hospital-acquired CDI (HA-CDI) has been a difficult problem for many years, but corresponding author Ljiljana Markovic-Denic, PhD, of the University of Belgrade, and colleagues, noted that some factors associated with the pandemic might have increased the risk of HA-CDI among patients whose COVID-19 cases were severe enough to warrant hospitalization.

“Alterations in gut microbiota due to empiric antibiotic treatments and experimental antiviral and immunomodulatory drugs increased the risk for HA-CDI,” they wrote.

However, the pandemic also changed the way hospitals were organized, with some countries devoting entire hospitals to COVID-19 cases. Such was the case at Serbia’s University Clinical

Hospital Center Bezanijska Kosa, the setting of the new study. During the course of the 36-month study period (from January 2019 through December 2021), the 325-bed hospital was converted to a COVID-only facility for 12 months. The investigators therefore decided to use the hospital to study whether HA-CDI risk varied among people with and without COVID-19, and whether it varied between the 12 months when the hospital exclusively treated COVID-19 cases and the 24 months when it did not treat patients with COVID-19.

The hospital reported 547 cases of CDI during the study period, and 341 of those cases were among people infected with SARS-CoV-2. The incidence rate for hospital-onset CDI (HO-CID) varied significantly between the times the hospital was and was not treating patients with COVID-19.

“The incidence density of HO-CDIs per 1,000 patients-days was 1.33 in the non-COVID period and 4.53 in the COVID period,” they wrote.

When the investigators examined the characteristics of patients with HA-CDI and COVID-19, they found that such patients were younger than HA-CDI patients without COVID-19. They were also more likely to be admitted from another hospital (20.5% versus 2.9%; p < 0.001) and were more likely to have previously had antimicrobial therapy (99.1% versus 91.3%; p < 0.001).

Independent risk factors for HA-CDI among people with COVID-19 were admission from another hospital, length of antibiotic administration, and the use of steroids in therapy. Among non-COVID-19 patients, independent risk factors for HA-CDI were older age, advanced-stage renal function, chemotherapy, and a low albumin level.

Denic and colleagues noted that prior to the pandemic, antibiotic stewardship programs and stepped-up infection-control measures led to a reduction in the rates of HA-CDI in many countries. However, the pandemic led to shifts in prescribing behaviors.

“Inappropriate antibiotic prescription in COVID units of primary healthcare centers in our country for patients with middle COVID-19 infections has led to the tremendous use of antibiotics, a well-known risk factor for CDI,” the authors noted. The same appears to be true in other countries. In North America, nearly two-third of people with COVID-19 received antibiotics in the first half of 2020, and in parts of east and southeast Asia, the rate was as high as 87.5%.

The authors said their study had important limitations, such as the single-center design. However, they said the single-center design was also beneficial in the sense that it allowed them to compare how COVID-19 affected HA-CDI risk in the same center, with the same staff and procedures.

“We believe that the increase in HAI-CDI in COVID-19 patients did not occur due to changes in infection control precautions and hygiene measures, given that the same infection control team performed continuous surveillance and organized preventive measures for all of the patients in both study periods,” they wrote.

Rather, they said, it is more likely that the higher level of HA-CDI risk in people with COVID-19 was associated by factors like being transferred from another hospital, changes in antibiotic use, and the use of steroids.