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Nutrition Associated With Recurrent CDI Risk in Elderly Patients


Elderly Japanese patients with a high geriatric nutritional risk index (GNRI) were associated with significantly better Clostridioides difficile infection (CDI) relapse-free survival compared with those with low GNRI.

The nutritional status of elderly patients may determine their risk of recurrent Clostridioides difficile infection (CDI), according to study findings published in Journal of Rural Medicine.

CDI recurrence is a significant health care burden contributing to high risk of morbidity, mortality, and cost. Older age (> 65 years) is known to be an important risk factor for recurrent CDI, and as the world’s aging population increases, researchers note that identifying risk for CDI in these elderly patients has become an urgent matter.

“Many recent studies have reported an association between nutritional status and various diseases. The geriatric nutritional risk index (GNRI) is a simple and objective tool that uses serum albumin levels and body mass index (BMI) to assess the nutritional status of older patients. A low GNRI has been reported to be an adverse prognostic factor in patients with various diseases,” explained the study authors.

They conducted a retrospective observational study to investigate the relationship between CDI relapse and nutritional status using the GNRI. Patients hospitalized between January 2016 and December 2021 at the Iwate Prefectural Senmaya Hospital, located in a rural area of Japan, were examined for the analysis.

Total hospitalization, mean patient age, and length of hospital stay (LOS) among the cohort of pateints were 219,022; 79.4 years; and 21.0 days, respectively. A total of 108 patients with fever and diarrhea received a CDI diagnosis during hospitalization, of which 19 were excluded because of younger age (< 65 years), early death within 14 days of the initial CDI diagnosis, and insufficient data.

The study cohort (N = 89) were divided into low- (< 75) and high-GNRI groups (≥ 75) based on the receiver operating characteristic curve analysis. Variables associated with CDI relapse were also analyzed, and they were age, sex, BMI, duration of hospitalization prior to the initial diagnosis of CDI, medical condition (chronic kidney disease [CKD]), antibiotics administered prior to the initial diagnosis of CDI, laboratory findings at initial diagnosis of CDI, severity of CDI, treatment for CDI, relapse of CDI, and LOS.

Overall, the median GNRI scores in all patients and in the low- and high-GNRI groups were 74.9, 68.9, and 83.9, respectively. Age was significantly higher in the low-GNRI group (P = .009), who also reported longer LOS (P = .003), vs the high-GNRI group. BMI and serum albumin levels, which are components of the GNRI, were significantly lower in the low-GNRI group than in the high-GNRI group.

Of the 89 patients, 28 (31.8%) experienced a CDI relapse. Findings of the log-rank test showed a significantly better relapse-free survival (RFS) in the high-GNRI group (P = .002).

Univariate analysis revealed that low GNRI (P = .004), CKD (P = .004) and beta-lactamase inhibitor administration before the initial diagnosis of CDI (P = .025) were significantly correlated with RFS. Multivariate analysis further revealed that low GNRI (P = .008) and CKD (P = .010) were independent prognostic factors for RFS.

“The GNRI is a simple and strong tool to assess the nutritional status of elderly patients; administration of vancomycin or fidaxomicin, which has a lower risk of treatment failure or relapse of CDI than metronidazole, should be considered for patients with CDI with low GNRI,” concluded the study authors.


Kumagai H, Shioi Y, Tamura D, Shitomi T, Tono C. Geriatric nutritional risk index as a risk-factor for Clostridioides difficile infection relapse in elderly Japanese patients. J Rural Med. 2022;17(4):248-254. doi:10.2185/jrm.2022-027

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