Overview of Clostridium difficile Infection in Cancer Patients
Clostridium difficile Associated Diarrhoea (CDAD) is the leading cause of nosocomial diarrhoea. Clostridium difficile Infections (CDIs) may be induced by medication or medical procedures that disrupt normal bowel flora or interfere with bowel motility. The emergence of hyper-virulent strains of CDI, reports of severe or recurrent CDI in immune competent populations, advent of various infection control challenges, and diagnostic and therapeutic dilemmas have contributed to a shift in the disease paradigm. However, there is insufficient data on the risk of CDI in vulnerable cancer patients receiving chemotherapy or who are admitted to health care settings for long periods of time. This review describes the epidemiology, risk factors, pathophysiology, and management of CDIs in cancer patients receiving chemotherapeutic agents.
Clostridium difficile (CD) is a gram-positive, spore-forming, anaerobic bacillus recognized as the most common cause of healthcare-associated infectious diarrhoea. Changes in bowel environment and function in cancer patients are common, primarily due to chemotherapy, radiation therapy, and iatrogenic processing. Stress, altered dietary habits, natural patient immunity, and treatment schedules may also play a role in these changes. Irrelevant to cancer stage and underlying disease, the rates of admission to healthcare units vary according to patient age at diagnosis, co-morbid conditions, and treatment-related complications. Admission rates among cancer patients are also relatively high compared to those in non-oncologic populations. Prolonged or increased frequency of hospital stays are well-known risk factors for Clostridium difficile Infection (CDI). Prolonged use of antibiotics or uses of broad spectrum of antibiotics that contribute to co-morbid conditions also play a major role in the development of CDIs. Although cancer patients receiving chemotherapy are at high risk for CDIs, diagnosis of CDI is difficult because stool culture and detection of cellular toxicity, both gold-standard diagnostic tools for diagnosis of CDI, are difficult to perform and take too much time. A recently published paper described the use of an Enzyme Immunoassay (EIA)test, which reportedly had low sensitivity (35-85%) and repeat tests reported its low positive predictive value.
Several articles related to CDI were study designs based on the general population. Even though it is already known that a large portion of high risk group is related to cancer patients and chemotherapy, there are only a few articles that analysed the data. Previous studies were mainly epidemiologic data which come from examination of outbreak rates after conducting single or combined regimen chemotherapy dependent on each cancer patients group. There are only a few studies that compared the degree of CDI outbreaks among chemotherapeutic agents or cancer types, respectively. In some studies, there were reports of CDI outbreaks in hematopoietic stem cell transplantation patients or advanced chronic kidney patients which incur immune compromised state.
Journal of Infectious Diseases and Diagnosis