Letter to the Editor
Clostridium difficile infection in oncohematologic patients
Infección por Clostridium difficile en pacientes oncohematológicos
Luis Angel Sánchez-Muñoz
, Laura Rodríguez-Fernández, Genoveva Zapico-Aldea
Corresponding author
Servicio de Medicina Interna, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines for CDI of 2014, includes immunodeficiency or severe comorbidity (B-<span class="elsevierStyleSmallCaps">II</span>) among the prognostic markers of severe CDI, with cancer being among them.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> All patients in this study suffer from haematology-oncology disease and immunosuppression (immunosuppressants, chemotherapy, radiotherapy, hematopoietic cell transplantation), so they would be episodes of severe CDI (or with increased risk of severe CDI) and the treatment advised would have been vancomycin (A-<span class="elsevierStyleSmallCaps">I</span>) or fidaxomicin (B-<span class="elsevierStyleSmallCaps">I</span>), in that order; with the use of oral metronidazole (D-<span class="elsevierStyleSmallCaps">I</span>)<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> being contraindicated. The novelty of the recent American Society for Infectious Diseases and Epidemiology (IDSA-SHEA) guidelines is that vancomycin and fidaxomicin are the treatment of choice in the first episodes of CDI (severe or non-severe, with the same level of evidence and recommendation), and in the first recurrences after initial treatment with vancomycin (with the same level of recommendation and greater evidence with fidaxomicin).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The high price of fidaxomicin has restricted its use to cases with multiple recurrences, although there is evidence that its use in patients with well-proven risk factors for recurrence or in certain groups of patients (cancer, concomitant antibiotic treatment or renal failure) improves outcomes.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In patients with haematological or solid tumours, fidaxomicin has demonstrated a sustained response rate greater than vancomycin,<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">3,4</span></a> estimating a gain of 0.016 quality-adjusted life years (QALY) and a saving of €2397 per patient.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Several initiatives have tried to rationalize and standardize the prescription of fidaxomicin in patients at high risk of recurrence, based on data from the literature (age, renal insufficiency, Horn index, previous episodes, no antibiotic discontinuation). The GEIH-CDI <span class="elsevierStyleItalic">score</span> recurrence prediction tool was recently published. It was validated in a prospective cohort of 183 patients and includes 4 factors: age (70–79 years and ≥80 years), history of CDI during the previous year, direct detection of toxin in stools and persistence of diarrhoea on the fifth day of treatment. This <span class="elsevierStyleItalic">score</span> allows to select patients with high risk (≥4 points; risk of recurrence >50%) and patients with low risk (0–1 points; risk of recurrence <10%) and can facilitate or support episode treatment selection.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In summary, vancomycin and fidaxomicin are the treatment of choice for any first episode of CDI, but it is necessary to rationalize their use, differentiating patients with a high risk of recurrence or with certain diseases in which the use of fidaxomicin is more cost-effective from the first episode.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sánchez-Muñoz LA, Rodríguez-Fernández L, Zapico-Aldea G. Infección por <span class="elsevierStyleItalic">Clostridium difficile</span> en pacientes oncohematológicos. Med Clin (Barc). 2019;153:e54.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Martín Rizo L, Malpartida Flores M, Fernández Lisón LC. Fidaxomicin in the treatment of <span class="elsevierStyleItalic">Clostridium difficile</span> infection in oncohematology patients [Article in English, Spanish]. 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