Impact of time to treatment in first occurrence, non-severe Clostridioides difficile infection for elderly patients: are we waiting too long to treat?

TL;DR

This study finds that delaying antibiotic treatment for non-severe C. difficile infections in elderly patients increases the risk of disease progression.

Contribution

The study identifies a 64-hour threshold for treatment initiation that is associated with reduced risk of severe C. difficile infection.

Findings

Delayed treatment (after 64 hours) was linked to a 4.6 times higher risk of disease progression.

Hospital-acquired infections and toxin positivity were more common in patients who progressed to severe disease.

The association between delayed treatment and progression remained significant across different statistical models.

Abstract

Data evaluating timeliness of antibiotic therapy in Clostridioides difficile infections (CDI) are not well established. The study’s purpose was to evaluate the impact of time-to-CDI treatment on disease progression.

A case–control study was performed among hospitalized patients with CDI from 1/2018 to 2/2022. Inclusion criteria were age ≥65 years, first occurrence, non-severe CDI at symptom onset, and CDI treatment for ≥72 hours. Cases included patients who progressed to severe or fulminant CDI; controls were patients without CDI progression. Time to CDI treatment was evaluated in three ways: a classification and regression tree (CART)-defined threshold, time as a continuous variable, and time as a categorical variable.

272 patients were included; 136 with CDI progression, 136 patients without. The median (IQR) age was 74 (69–81) years, 167 (61%) were women, and 108 (40%) were immunosuppressed. CDI progression patients more commonly were toxin positive (66 [49%] vs 52 [38%], P = .087) with hospital-acquired disease (57 [42%] vs 29 [21%], P < 0.001). A CART-derived breakpoint for optimal time-to-CDI treatment of 64 hours established early (184, 68%) and delayed treatment (88, 32%). When accounting for confounding variables, delayed CDI treatment was associated with disease progression (adjOR, 4.6; 95%CI, 2.6–8.2); this was observed regardless of how time-to-CDI-active therapy was evaluated (continuous adjOR, 1.02; categorical adjOR, 2.11).

Delayed CDI treatment was associated with disease progression and could represent an important antimicrobial stewardship measure with future evaluation.

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