Comparison of Risk Stratification Approaches to Identify Patients with Clostridioides difficile Infection at Risk for Multidrug-Resistant Organism Gut Microbiota Colonization

Evan J Zasowski; Maryam Ali; Ada Anugo; Nayle Ibragimova; Kierra M Dotson; Bradley T Endres; Khurshida Begum; M Jahangir Alam; Kevin W Garey

doi:10.1007/s40121-023-00843-9

Comparison of Risk Stratification Approaches to Identify Patients with Clostridioides difficile Infection at Risk for Multidrug-Resistant Organism Gut Microbiota Colonization

Infect Dis Ther. 2023 Aug;12(8):2005-2015. doi: 10.1007/s40121-023-00843-9. Epub 2023 Jul 12.

Authors

Evan J Zasowski^{1

2}, Maryam Ali³, Ada Anugo³, Nayle Ibragimova⁴, Kierra M Dotson³, Bradley T Endres³, Khurshida Begum³, M Jahangir Alam³, Kevin W Garey³

Affiliations

¹ Department of Clinical Sciences, Touro University California College of Pharmacy, Vallejo, CA, USA. ezasowski.pharmd@gmail.com.
² Department of Clinical Pharmacy, UCSF School of Pharmacy, San Francisco, CA, USA. ezasowski.pharmd@gmail.com.
³ Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA.
⁴ Department of Clinical Sciences, Touro University California College of Pharmacy, Vallejo, CA, USA.

Abstract

Introduction: Multidrug-resistant organisms (MDRO) commonly colonize the gut microbiota of patients with Clostridioides difficile infection (CDI). This increases the likelihood of systemic infections with these MDROs. To help guide MDRO screening and/or empiric antibiotic therapy, we derived and compared predictive indices for MDRO gut colonization in patients with CDI.

Methods: This was a multicenter, retrospective cohort study of adult patients with CDI from July 2017 to April 2018. Stool samples were screened for MDRO via growth and speciation on selective antibiotic media and confirmed using resistance gene polymerase chain reaction. A regression-based risk score for MDRO colonization was constructed. Predictive performance via area under the receiver operating characteristic curve (aROC) of this index was compared with two other simplified risk stratification approaches: (1) prior healthcare exposure and/or high-CDI risk antibiotics; (2) number of prior high-CDI risk antibiotics.

Results: 50 (20.8%) of 240 included patients had MDRO colonization; 35 (14.6%) VRE, 18 (7.5%) MRSA, 2 (0.8%) CRE. Prior fluoroquinolone (aOR 2.404, 95% CI 1.095-5.279) and prior vancomycin (1.996, 95% CI 1.014-3.932) were independently associated with MDRO colonization while prior clindamycin (aOR 3.257, 95% CI 0.842-12.597) and healthcare exposure (aOR 2.138, 95% CI 0.964-4.740) were retained as explanatory variables. The regression-based risk score significantly predicted MDRO colonization (aROC 0.679, 95% CI 0.595-0.763), but was not significantly more predictive than prior healthcare exposure + prior antibiotics (aROC 0.646, 95% CI 0.565-0.727) or number of prior antibiotic exposures (aROC 0.642, 95% CI 0.554-0.730); P > 0.05 for both comparisons.

Conclusion: A simplified approach using prior healthcare exposure and receipt of prior antibiotics known to increase CDI risk identified patients at risk for MDRO gut microbiome colonization as effectively as individual patient/antibiotic risk modeling.

Keywords: Antimicrobial stewardship; CDI; CRE; MRSA; VRE.