Clostridium difficile infection (CDI) is a common infection in patients undergoing allogeneic stem cell transplantation (allo-SCT), with reported incidence ranging from 9 to 24% in the first 100 days, post transplantation [1–4]. The signs and symptoms of CDI bear resemblance to patients with acute gastrointestinal graft versus host disease (GI GVHD), making it difficult to differentiate between these two common complications of allo-SCT [5]. It has also been reported that the development of either CDI or GI GVHD can increase the risk of subsequent development of the other in the post-transplant period [1]. We examined the relationship between CDI and GI GVHD in the related and unrelated allo-SCT.
At our center, combination of tacrolimus, mycophenolate mofetil plus ATG (TM-thymo) at a total dose of 4.5 mg/kg as GVHD prophylaxis (IV infusion over 3 days: day −3, 0.5 mg/kg; day −2, 1.5 mg/kg; and day −1, 2.5 mg/kg) is used for all unrelated donor transplants since 2012; we previously reported excellent outcomes with relatively low rate of grade III–IV acute GVHD [6, 7]. For the matched related donor transplants and matched unrelated donor transplants done prior to 2012 we used a combination of tacrolimus and mycophenolate mofetil for GVHD prophylaxis. Mechanism of action of ATG in GVHD prevention is mediated through in vivo depletion of T cells, thus activation and expansion of effector cells are effectively attenuated [8]. The consequence of this action also can subject patients to increased risk of infections [7].
We retrospectively studied a total of 310 consecutive patients in 2 cohorts who underwent allo-SCT at our institution between 2009 and 2013. Two distinct cohorts were: 100 patients who received related donors (group 1, transplanted between 3/2010–12/2013), and 210 patients who received unrelated (group 2 transplanted between 12/2009–12/2013) allo-SCT. This study protocol was approved by Wayne State University Institutional Review Board. CDI was defined as infection in a patient with diarrhea and a positive result of a laboratory assay for toxigenic clostridium difficile qPCR in the stool.
Descriptive statistics were used to summarize demographic and baseline characteristics among study populations. Chi-square (or Fisher’s exact) and Kruskal–Wallis tests were used to compare among groups for categorical and continuous variables, respectively. The Kaplan–Meier method was used to describe the distributions of CDI-free survival (CFS), acute GI GVHD-free survival (giGFS), acute GVHD-free survival (aGFS), and overall survival (OS) after treatment. CFS, giGFS, and aGFS were defined as the time from transplantation to development of C. difficile, acute GI GVHD, and acute GVHD, respectively, and to death from any cause; OS was defined as the time from transplantation to death from any cause. Univariate and multivariable Cox proportional hazards regression models were fitted to assess associations between patient characteristics and survival benefit (CFS, giGFS, aGFS, and OS).
Baseline characteristics of the two groups are outlined in Table 1. All patients received acyclovir/fluconazole/norfloxacin for prophylaxis against infections and received daily GCSF starting on day 6 post-transplant until neutrophil engraftment. The median follow-up of OS for the two groups was 2.43 years (95% CI, 2.22–2.87).
Table 1.
Baseline characteristics
| Matched related allogeneic (N = 100) |
Unrelated allogeneic (N = 210) |
P-value | |
|---|---|---|---|
| Age at Transplant – median (range) | 54 (19, 59.25) | 56 (20, 62) | 0.21 |
| Gender – count (%) | 0.57 | ||
| Female | 42 (42) | 97 (46) | |
| Male | 58 (58) | 113 (54) | |
| Race – count (%) | 0.01 | ||
| African-American (AA) | 13 (13) | 8 (4) | |
| Caucasian (EA) | 83 (83) | 190 (90) | |
| Others | 4 (4) | 12 (6) | |
| Conditioning regimen – count (%) | 0.04 | ||
| MAC | 68 (68) | 116 (55) | |
| RIC | 32 (32) | 94 (45) | |
| Diagnosis – ?count (%) | 0.20 | ||
| Leukemia | 48 (48) | 120 (57) | |
| Lymphoma | 29 (29) | 39 (19) | |
| MDS | 12 (12) | 29 (14) | |
| Other | 11 (11) | 22 (10) | |
| Source of stem ?cells – count (%) | 0.85 | ||
| BM | 9 (9) | 16 (8) | |
| PBSC | 91 (91) | 194 (92) | |
| HLA match – ?count (%) | <0.001 | ||
| 10/10 | 93 (93) | 138 (66) | |
| Others | 6 (6) | 68 (32) | |
| Missing | 1 (1) | 4 (2) | |
| GVHD prophylaxis – count (%) | <0.001 | ||
| TACRO/MMF | 97 (97) | 100 (48) | |
| TACRO/MMF/THYMO | 0 (0) | 101 (48) | |
| Other | 3 (3) | 9 (4) |
TACRO tacrolimus, MMF mycophenolate mofetil, THYMO anti–thymocyte globulin
The cumulative incidence of CDI was 18% (95% CI, 11–26%) vs 26.7% (95% CI, 19–30%) in groups 1 and 2 respectively (p = 0.24;). The median time to development of CDI was 12.5 days (range D-3 to D 113) in group 1 and 16 days (range D-3 to D209) in group 2. In a multivariable Cox regression analysis for risk factors for development of CDI, steroid use for GVHD was the only risk factor independently predictive of increased incidence of CDI (HR, 2.28; 95% CI, 1.29–4.05; p < 0.001) (Table 2). We decided not to include use of beta-lactam antibiotics in our analysis because most (>90%) patients received beta-lactam antibiotics in the post-transplant period.
Table 2.
Univariable and multivariable Cox regression analyses for development of CDI
| Unadjusted | Adjusted | |||
|---|---|---|---|---|
| HR (95% CI) | P-value | HR (95% CI) | P-value | |
| Age at transplant | 1 (0.98, 1.02) | 0.77 | 0.99 (0.96, 1.01) | 0.28 |
| Steroid use for GVHD | ||||
| No | Reference | Reference | ||
| Yes | 2.03 (1.27, 3.23) | <0.001 | 2.28 (1.29, 4.05) | <0.001 |
| Race | ||||
| Caucasian | Reference | Reference | ||
| African American | 1.11 (0.45, 2.75) | 0.83 | 1.58 (0.53, 4.7) | 0.41 |
| Others | 1.63 (0.71, 3.77) | 0.25 | 1.18 (0.44, 3.13) | 0.75 |
| Diagnosis | ||||
| Leukemia | Reference | Reference | ||
| Lymphoma | 1.11 (0.63, 1.96) | 0.72 | 0.97 (0.5, 1.86) | 0.92 |
| MDS | 1.59 (0.88, 2.88) | 0.13 | 1.56 (0.8, 3.04) | 0.19 |
| Other | 0.45 (0.16, 1.26) | 0.13 | 0.47 (0.16, 1.4) | 0.18 |
| Regimen intensity | ||||
| MAC | Reference | Reference | ||
| RIC | 1.22 (0.78, 1.93) | 0.38 | 1.51 (0.86, 2.66) | 0.15 |
| Group | ||||
| Matched related allogeneic | Reference | Reference | ||
| Unrelated allogeneic | 1.6 (0.94, 2.72) | 0.08 | 1.41 (0.71, 2.8) | 0.33 |
| HLA match | ||||
| 10/10 | Reference | Reference | ||
| 9/10 | 1.59 (0.92, 2.73) | 0.10 | 1.10 (0.56, 2.17) | 0.79 |
| <9/10 | 0.49 (0.15, 1.56) | 0.23 | 0.40 (0.11, 1.39) | 0.15 |
| ATG use | ||||
| No | Reference | Reference | ||
| Yes | 1.17 (0.74, 1.87) | 0.50 | 1.02 (0.55, 1.88) | 0.95 |
| Acute GI GVHD | ||||
| No | Reference | Reference | ||
| Yes | 1.69 (0.78, 3.69) | 0.19 | 1.01 (0.43, 2.39) | 0.98 |
GVHD Graft versus host disease; MDS Myelodysplastic syndrome; MAC Myeloablative conditioning; RIC reduced intensity conditioning; HLA Human leukocyte antigen; ATG Anti–thymocyte globulin; HR Hazard ratio.
The incidence of GI GVHD was higher in group 2 as compared to group 1 (33 vs 23%) and correspondingly the use of systemic steroids was higher in group 2 (45 vs 33%). The median time to development of GVHD was 39 days in group 1 and 28 days in group 2. Among the patients with CDI, 38% (7/18) in group 1 and 42% (24/57) also developed GI GVHD. In patients who developed both CDI and GI GVHD, CDI preceded GI GVHD in all patients (7/7) in group 1 and in 67% (16/24) of patients in group 2. Eight patients in group 2 developed CDI after development of GI GVHD. Majority of patients (95%) with a diagnosis of GI GVHD underwent GI biopsy to confirm the diagnosis including all patients who developed both CDI and GVHD. Rate of stage 3–4 GI GVHD was 35% (8/23) in group 1 and 30% (21/70) in group 2.
Development of CDI increased the subsequent risk of development of GI GVHD. Patients who developed CDI had a statistically significant higher probability of developing acute GI GVHD (HR, 1.92; 95% CI, 1.15–3.19; p = 0.01) (Fig. 1). In a multivariable Cox regression, independent covariates associated with acute GI GVHD were CDI, diagnosis of lymphoma, unrelated donor transplant, use of ATG, and HLA mismatch. Development of acute GI GVHD was associated with increased mortality (HR 1.7; 95% CI, 1.15–2.5; p = 0.01) while development of CDI had no effect on OS.
Fig. 1.
Rates of development of subsequent GI GVHD in patients with and without prior CDI
To our knowledge this is the largest report of CDI among recipients of allo-SCT. We confirmed the high incidence of CDI in this patient population approaching 27% in recipients of unrelated donor transplants [1–4]. Similarly, our study confirms that the highest incidence of CDI is during pre-engraftment period within the first 2 weeks after transplantation, which correlates with the duration of neutropenia and antibiotic use. In addition, CDI can complicate therapy of GI GVHD with increased incidence with use of systemic steroids.
Our study confirms the earlier preliminary findings of increased risk of GI GVHD in patients who develop CDI in the post-transplant period [1]. One of the mechanisms of GVHD includes tissue inflammation leading to release of cytokines leading to activation of immune system [5]. We hypothesize that CDI causes worsening tissue injury and inflammation in the gut thus increasing the risk for GI GVHD. The other mechanism linking the two diagnoses may be decreased/altered microbial diversity, which is seen both in patients with CDI [9] and with GI GVHD [10]. Thus, reducing the incidence of CDI may help reduce the incidence of GI GVHD. Since colonization with Clostridium difficile prior to hematopoietic stem cell transplantation has been shown to be a significant risk factor for later development of CDI [11], further studies to identify the high risk patients and using prophylactic strategies to eliminate Clostridium difficile may help reduce the incidence of gastrointestinal graft-versus-host disease.
Footnotes
Conflict of interest The authors declare that they have no conflict of interest.
References
- 1.Alonso CD, Treadway SB, Hanna DB, Huff CA, Neofytos D, Carroll KC, et al. Epidemiology and outcomes of Clostridium difficile infections in hematopoietic stem cell transplant recipients. Clin Infect Dis. 2012;54:1053–63. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Chopra T, Chandrasekar P, Salimnia H, Heilbrun LK, Smith D, Alangaden GJ. Recent epidemiology of Clostridium difficile infection during hematopoietic stem cell transplantation. Clin Transplant. 2011;25:E82–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Hosokawa K, Takami A, Tsuji M, Araoka H, Ishiwata K, Takagi S, et al. Relative incidences and outcomes of Clostridium difficile infection following transplantation of unrelated cord blood, unrelated bone marrow, and related peripheral blood in adult patients: a single institute study. Transpl Infect Dis. 2014;16:412–20. [DOI] [PubMed] [Google Scholar]
- 4.Zacharioudakis IM, Ziakas PD, Mylonakis E. Clostridium difficile infection in the hematopoietic unit: a meta-analysis of published studies. Biol Blood Marrow Transplant. 2014;20:1650–4. [DOI] [PubMed] [Google Scholar]
- 5.Couriel D, Caldera H, Champlin R, Komanduri K. Acute graft-versus-host disease: pathophysiology, clinical manifestations, and management. Cancer. 2004;101:1936–46. [DOI] [PubMed] [Google Scholar]
- 6.Ratanatharathorn V, Deol A, Ayash L, Cronin S, Bhutani D, Lum LG, et al. Low-dose antithymocyte globulin enhanced the efficacy of tacrolimus and mycophenolate for GVHD prophylaxis in recipients of unrelated SCT. Bone Marrow Transplant. 2015;50:106–12. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Bacigalupo A, Lamparelli T, Bruzzi P, Guidi S, Alessandrino PE, di Bartolomeo P, et al. Antithymocyte globulin for graft-versus-host disease prophylaxis in transplants from unrelated donors: 2 randomized studies from Gruppo Italiano Trapianti Midollo Osseo (GITMO). Blood. 2001;98:2942–7. [DOI] [PubMed] [Google Scholar]
- 8.Mohty M Mechanisms of action of antithymocyte globulin: T-cell depletion and beyond. Leukemia. 2007;21:1387–94. [DOI] [PubMed] [Google Scholar]
- 9.Antharam VC, Li EC, Ishmael A, et al. Intestinal dysbiosis and depletion of butyrogenic bacteria in Clostridium difficile infection and nosocomial diarrhea. J Clin Microbiol. 2013;51:2884–92. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Staffas A, Burgos da Silva M, van den Brink MR. The intestinal microbiota in allogeneic hematopoietic cell transplant and graft-versus-host disease. Blood. 2017;129:927–33. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Jain T, Croswell C, Urday-Cornejo V, Awali R, Cutright J, Salimnia H, et al. Clostridium difficile colonization in hematopoietic stem cell transplant recipients: a prospective study of the epidemiology and outcomes involving toxigenic and nontoxigenic strains. Biol Blood Marrow Transplant. 2016;22: 157–63. [DOI] [PubMed] [Google Scholar]