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Clostridioides difficile Infection Risk Greater Among Patients Requiring Maintenance Hemodialysis


Patients requiring maintenance hemodialysis (MHD) had a 4-fold higher risk of Clostridioides difficile infection (CDI), with rates of CDI increasing over time regardless of MHD requirement.

Patients requiring maintenance hemodialysis (MHD) were associated with a significantly greater risk of developing Clostridioides difficile infection (CDI), according to study findings published recently in Infection Control & Hospital Epidemiology.

Among the most common causes of health care–associated infections, CDI poses considerable morbidity and mortality risk to those affected. Rates of CDI have been increasing in both hospital and community settings, noted researchers, in which people with chronic kidney disease (CKD) and those on MHD are at high risk due to substantial antimicrobial exposure, frequent hospitalizations, and immune dysfunction.

“Rates of CDI and associated mortality are up to 2-fold higher among persons with CKD compared with the general population, and the requirement for MHD increases these rates even further,” they added.

“Given the clinical significance of CDI among persons requiring MHD and increasing CDI rates in health care settings, we evaluated the burden of CDI, potential risk factors for CDI, mortality rates, and mortality-associated risk factors among persons requiring MHD.”

Researchers conducted a systematic review and meta-analysis of studies reporting rates of CDI among persons requiring MHD in MEDLINE, Embase, Web of Science Core Collection, CINAHL, and Cochrane Central Register of Controlled Trials databases between May 17, 2021, and March 4, 2022.

The prevalence of CDI among persons requiring MHD was compared with that of persons not requiring MHD, with trends of CDI over time among both groups also evaluated. Due to only 3 studies meeting the inclusion and exclusion criteria on reported rates of mortality associated with CDI among persons requiring MHD, a meta-analysis could not be performed for this topic.

A total of 2408 studies met eligibility criteria, of which 240 underwent full text review. Among these studies, 15 reports provided data on rates of CDI among persons requiring MHD and 8 studies provided rates among persons not requiring MHD. All studies included in the meta-analysis were deemed high quality, with Newcastle Ottawa Scale scores of 7 of 7 stars for 8 studies and 6 of 7 stars for 2 studies.

Compared with people not requiring MHD, those requiring MHD showed a higher pooled prevalence of CDI and a more than 4-fold greater risk of developing the infection (19.14% vs 5.16%; odds ratio [OR], 4.35; 95% CI, 2.07-9.16; P = .47).

Moreover, the linear increase in CDI over time was significant for both groups, increasing an average of 31.97% annually between 1993 and 2017 (OR, 1.32; 95% CI, 1.1-1.58; P < .01). The linear annual increase was similar among persons requiring and not requiring MHD (OR, 1.28; 95% CI, 1.13-1.45; P = .11).

Of the studies comparing mortality rates among persons on MHD with and without CDI, mortality was shown to be significantly higher among persons requiring MHD, with a 2-fold higher risk of death. Independent factors associated with mortality were cited in one study, which included being 65 years or older and presence of cirrhosis.

Changes in diagnostic testing for CDI over the study period, such as nucleic acid amplification tests, was identified as a possible limitation of the study, as it may have identified colonization in the presence of diarrhea from other causes, leading to higher reported rates of CDI in studies published after 2005.

“CDI causes a substantial burden on persons requiring MHD, with higher mortality rates compared with persons not requiring MHD,” concluded the study authors. “Adherence to CDI-specific prevention recommendations and improving antimicrobial prescribing patterns are some of the important strategies to limit CDI spread in the population of patients requiring MHD."


Elfanagely YM, Tanzer JR, Shobayo A, et al. Prevalence and trends of Clostridioides difficile infection among persons requiring maintenance hemodialysis: A systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2022;1-8. doi:10.1017/ice.2022.217

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