Impact of Clostridioides difficile infection on survival and graft-versus-host disease after allogeneic hematopoietic cell transplantation: a multicenter study on behalf of the Polish Adult Leukemia Group

Abstract Clostridioides difficile infection (CDI) is the most common cause of infectious diarrhea after allogeneic hematopoietic cell transplantation (allo-HCT). The impact of CDI and its treatment on allo-HCT outcomes and graft-versus-host disease (GVHD), including gastrointestinal GVHD (GI-GVHD) is not well established. This multicenter study assessed real-life data on the first-line treatment of CDI and its impact on allo-HCT outcomes. Retrospective and prospective data of patients with CDI after allo-HCT were assessed. The first-line treatment for CDI included metronidazole in 34 patients; vancomycin, in 64; and combination therapy, in 10. Treatment failure was more common with metronidazole than with vancomycin (38.2% vs. 6.2%; P <0.001). The need to administer second-line treatment was associated with the occurrence or exacerbation of GVHD ( P <0.05) and GI-GVHD ( P <0.001) and reduced overall survival ( P <0.05). In the multivariate analysis, the risk of death was associated with acute GVHD presence before CDI (hazard ratio[HR], 3.19; P =0.009) and the need to switch to second-line treatment (HR, 4.83; P <0.001). The efficacy of the initial CDI treatment affects survival and occurrence of immune-mediated GI-GVHD after allo-HCT. Therefore, agents with higher efficacy than metronidazole (vancomycin or fidaxomicin), should be administered as the first-line treatment.