Strategies to prevent adverse outcomes following Clostridioides difficile infection in the elderly

ABSTRACT

Introduction

Clostridioides difficile remains the most common cause of healthcare-associated infections in the US, and it disproportionately affects the elderly. Older patients are more susceptible and have a greater risk of adverse outcomes from C. difficile infection (CDI), despite advances in treatment and prevention.

Areas covered

The epidemiology and pathogenesis of CDI, as well as risk factors in the aging host, will be reviewed. The importance of antimicrobial stewardship and infection prevention in order to avoid acquisition and transmission will be discussed, as well as strategies to prevent adverse outcomes and recurrent CDI, through optimization of CDI treatment s,election.

Expert opinion

Appropriate CDI-prevention strategies to avoid adverse outcomes in this susceptible population involve antimicrobial stewardship and methods to prevent C. difficile transmission in healthcare settings. Management strategies to prevent adverse outcomes include initiation of supportive therapy and proper selection of CDI specific treatments. Many patients may also benefit from adjunctive therapies or additional procedures.

KEYWORDS:

• Adverse outcomes
• antimicrobial stewardship
• Clostridioides difficile
• elderly
• infection prevention

Article highlights

• Clostridioides difficile infection (CDI) is the most common infectious cause of healthcare-associated diarrhea and particularly impacts the elderly.

• Older patients are at greater risk of adverse outcomes, including treatment failure, severe and recurrent disease, hospital readmission, transfer to long-term care facilities, and death.

• The elderly have more risk factors for CDI, but immunosenescence and alteration in gut microbiota may also play a role in the development of CDI.

• Antibiotic exposure is the most important risk factor for development of CDI, reinforcing the need to focus on antimicrobial stewardship and infection prevention.

• Vancomycin and fidaxomicin are the cornerstones of treatment. Metronidazole is no longer recommended as a stand-alone first-line agent. Early surgical consultation should be obtained in fulminant cases.

• Preventing recurrent CDI remains a challenge. Appropriate CDI treatment antibiotic selection and management can decrease risk for recurrent CDI, and monoclonal antibodies and intestinal microbiota restoration therapy can decrease the risk of recurrence as well.

• Additional measures to prevent CDI, such as vaccination, are needed, particularly in the elderly.

Declaration of interest

M Olsen reports consulting work with Pfizer and grants from Sanofi Pasteur, Pfizer and Merck. E Dubberke reports research funding from Pfizer, Synthetic Biologics, Rebiotix and consulting work with Pfizer, Sanofi, Synthetic Biologics, Rebiotix. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.