Findings from a study by researchers from the University of Iowa highlights the potential role of the home environment in Clostridioides difficile transmission.
Using data from a commercial insurance claims database, the researchers found that the incidence of C difficile infection (CDI) among individuals living with a family member who had CDI was more than 12 times greater than the incidence in those without prior family exposure. The incidence rate was even higher in certain groups less likely to have other risk-increasing exposures.
While the level of absolute CDI risk attributable to the household transmission was extremely low, the authors of the study say the findings may have practical implications for preventing the spread of CDI in households.
CDI can be spread in the community
C. difficile infection (CDI) is a common, typically hospital-acquired infection that is mainly associated with antibiotic use and healthcare settings. While antibiotics create the conditions that allow for C difficile to flourish in the gut and cause infection, spores shed by infected patients (through fecal matter) and can be spread by healthcare workers and are frequently found on *bed rails, in the patient bathrooms, and other parts of the hospital environment.
(*High touch areas can be easily contaminated with Clostridioides difficile (C. difficile, C. diff.) spores) cdf note.
Those spores are often difficult to eliminate because they are resistant to many cleaning agents.
In 2017, according to the most recent data from the Centers for Disease Control and Prevention, there were an estimated 223,900 CDI cases in hospitalized patients.
But not all CDI cases start in hospitals. Some studies have found that CDI can be transmitted outside of healthcare settings, with persistent contamination of the household environment occurring in patients with documented infection. Others have found household pets colonized with the bacterium.
To better understand the potential role of household C difficile transmission, the University of Iowa researchers used a large population-based, commercial insurance claims data set to examine whether family members of CDI patients had a greater risk of acquiring the infection. Limiting the analysis to households with two or more family member enrolled in the same insurance plan for an entire month, they grouped individuals into four categories based on CDI status and family exposure to CDI: (1) CDI and prior family exposure, (2) no CDI and prior family exposure, (3) CDI and no family exposure, and (4) no CDI and no family exposure.
The primary outcome of the case-control study was the incidence of CDI in a given monthly enrollment stratum. Aside from exposure to CDI diagnosed in a family member, other CDI exposure risks were considered, including prior hospitalization, age, and antibiotic use. The researchers also conducted a separate analysis for CDI diagnosed in hospital or outpatient settings.
Higher risk from family exposure
Analysis of data covering 2001 through 2017 found that 224,818 CDI cases, representing 194,424 enrollees, occurred in families with at least two enrollees. Of these, 1,074 CDI cases (0.48%) occurred following a diagnosis in a separate family member, representing possible transmission. In general, the index cases of CDI tended to occur in older enrollees (ages 45 to 64 years), while the CDI cases that represented potential transmission events occurred in children.
A comparison of the incidence rate ratio (IRR) between individuals with and without family exposure showed that prior family exposure was significantly associated with an increased incidence of CDI (IRR, 12.47; 95% confidence interval [CI], 8.86 to 16.97) even after controlling for other risk factors. This was the second-highest IRR behind hospital exposure (IRR, 16.18; 95% CI, 15.31 to 17.10).
Increased CDI incidence was also associated with age (IRR, 9.90; 95% CI, 8.93 to 10.98 for people over age 65 compared with those aged 0 to 17) and antibiotic use (IRR, 7.78; 95% CI, 7.33 to 8.25 for people on high-CDI-risk antibiotics compared with no antibiotics).
When the researchers looked at subgroups of CDI cases less likely to be attributed to hospital exposure, they found that the IRR associated with family exposure was even higher—16.00 (95% CI, 11.72 to 21.22) for community-onset CDI and 21.74 (95% CI, 15.12 to 30.01) for community-onset CDI without prior hospitalization.
“For individuals with family exposure, the risk for being diagnosed with CDI remained consistent after controlling for CDI risk factors and different model specifications,” the authors wrote. “Together, these results suggest that individuals with family exposure may be at greater risk for acquiring CDI than those without exposure and highlight the importance of the shared environment in the transmission and acquisition of C difficile.”
The authors note that because they were not able to conduct whole-genome sequencing, they cannot confirm whether CDI cases within families represent identical strains. They also said the study is limited by the reliance on insurance claims data, which do not provide all the details necessary to determine attributable risk.
Despite the low absolute risk of acquiring CDI from a family member, the authors suggested that cleaning shared bathrooms with effective cleaning agents could be a practical way to minimize transmission risk.
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With Doctor Teena Chopra, MD,MPH,FACP,FIDSA,FSHEA
Associate Professor of Medicine,Division of Infectious Diseases,
Corporate Medical Director,Infection Prevention,Epidemiology,and Antibiotic Stewardship ,DMC and WSU Director,Infection Prevention,Epidemiology and Antibiotic Stewardship,Vibra Hospital
Dr. Chopra will lead the discussion with an overview of a C. difficile infection followed by Alba Muhlfeld, and Renata Johnson, C. diff. Survivors both sharing their journey and providing
key-points to our global listeners.
Merck (NYSE: MRK), known as MSD outside the United States and Canada, announced on January 27, 2020, that the U.S. Food and Drug Administration (FDA) has approved a New Drug Application (NDA) for DIFICID® (fidaxomicin) for oral suspension, and a supplemental New Drug Application (sNDA) for DIFICID tablets for the treatment ofClostridioides (formerly Clostridium) difficile-associated diarrhea (CDAD) in children aged six months and older.1
DIFICID is a macrolide antibacterial medicine indicated in adults and pediatric patients aged 6 months and older for the treatment of CDAD.
To reduce the development of drug-resistant bacteria and maintain the effectiveness of DIFICID and other antibacterial drugs, DIFICID should be used only to treat infections that are proven or strongly suspected to be caused by Clostridioides difficile (C. difficile).
DIFICID is contraindicated in patients who have known hypersensitivity to fidaxomicin or any other ingredient in DIFICID. DIFICID should only be used for the treatment of CDAD. DIFICID is not expected to be effective for the treatment of other types of infections due to minimal systemic absorption of fidaxomicin.
“C. difficile is an important cause of health care- and community-associated diarrheal illness in children and sustained cure is difficult to achieve in some patients. The fidaxomicin pediatric trial was the first randomized controlled trial of C. difficile infection treatment in children,” said Dr. Larry K. Kociolek, Associate Medical Director of Infection Prevention and Control at Ann & Robert H. Lurie Children’s Hospital of Chicago. “I am very excited to have a new C. difficile infection treatment option for my pediatric patients.”
“Merck is committed to developing new treatments, as well as expanding indications of existing ones, in order to provide more solutions to treat infectious diseases, particularly among children,” said Dr. Nicholas Kartsonis, senior vice president, clinical research, infectious diseases and vaccines, Merck Research Laboratories. “C. difficile infection is an urgent public health challenge. We are grateful to the health care practitioners, the patients and their families for their invaluable contributions in helping to bring this new pediatric indication and the oral suspension formulation for DIFICID to the U.S. market.”
Both applications received a priority review classification by the FDA. The investigational pediatric indication for DIFICID was granted Orphan Drug Designation in 2010.
Data Supporting the Approval of DIFICID in Pediatric Patients
The FDA’s approval of the new formulation and new indication for DIFICID was based on a Phase 3, multicenter, investigator-blind, randomized, parallel-group study (known as the SUNSHINE study, NCT02218372), in which the safety and efficacy of fidaxomicin was evaluated in pediatric patients from 6 months to less than 18 years of age (one patient was less than six months of age). This study, sponsored by Astellas Pharma Europe B.V. (with Merck & Co., Inc. as collaborator) included 148 randomized patients aged <18 years with confirmed CDI, of whom 142 received either fidaxomicin (suspension or tablets, twice daily) or vancomycin (suspension or tablets, four times daily) in a 2:1 ratio. Patients were randomized by age group, as follows: 30 patients from 6 months to <2 years; 49 patients age 2 to <6 years, 40 patients age 6 to <12 years and 29 patients age 12 to <18 years. Generally, the two treatment groups were balanced regarding demographics and other baseline characteristics. CDAD clinical response in the overall pediatric population, assessed through two days following 10 days of treatment, was similar between the fidaxomicin and vancomycin groups (77.6% vs. 70.5% with a 95% CI for the treatment difference of 7.5 [-7.4%, 23.9%]). Sustained clinical response, defined as the proportion of treated patients with confirmed clinical response and no CDAD recurrence through 30 days after the end of treatment, was higher for fidaxomicin than for vancomycin (68.4% vs. 50.0% with a 95% CI for the treatment difference of 18.4 [1.5%, 35.3%]).
The safety of DIFICID in pediatric patients 6 months to less than 18 years of age was evaluated in a Phase 2 single-arm trial in 38 patients and a Phase 3 randomized, active-controlled trial in 98 patients treated with DIFICID and 44 patients treated with vancomycin. Treatment discontinuation due to adverse reactions occurred in 7.9% (3/38) of patients in the Phase 2 trial, and in 1% (1/98) and 2.3% (1/44) of DIFICID- and vancomycin-treated patients, respectively, in the Phase 3 trial. The most common selected adverse reactions occurring in ≥5% of pediatric patients treated with DIFICID in the Phase 3 trial were pyrexia (13.3%), abdominal pain (8.2%), vomiting (7.1%), diarrhea (7.1%), constipation (5.1%), increased aminotransferases (5.1%) and rash (5.1%). One death occurred in the Phase 2 single-arm trial and three deaths occurred in the Phase 3 trial of DIFICID-treated patients. No deaths occurred in vancomycin-treated patients during the study period (40 days). All deaths occurred in patients less than 2 years of age and appeared to be related to underlying comorbidities.
Clostridioides (formerly Clostridium)difficile, also known as C. difficile or C. diff, is one of the most common causes of healthcare-associated infections in U.S. hospitals.2 Recent estimates suggest C. difficile causes almost 500,000 infections annually in the United States and is associated with approximately 29,000 deaths within 30 days of initial diagnosis.3 According to the CDC’s Antibiotic Resistance Threats in the United States, 2019 (2019 AR Threats Report), C. difficile is categorized as an urgent threat and is stated as a public health threat that requires urgent and aggressive action.4
Important Safety Information about DIFICID (fidaxomicin)
DIFICID is contraindicated in patients who have known hypersensitivity to fidaxomicin or any other ingredient in DIFICID.
Acute hypersensitivity reactions, including dyspnea, rash, pruritus, and angioedema of the mouth, throat, and face have been reported with DIFICID. If a severe hypersensitivity reaction occurs, DIFICID should be discontinued and appropriate therapy should be instituted.
DIFICID is not expected to be effective for the treatment of other types of infections due to minimal systematic absorption of fidaxomicin. DIFICID has not been studied for the treatment of infections other than CDAD. DIFICID should only be used for the treatment of CDAD.
Only use DIFICID for infection proven or strongly suspected to be caused by C. difficile. Prescribing DIFICID in the absence of a proven or strongly suspected C. difficile infection is unlikely to provide benefit to the patient and increases the risk of development of drug-resistant bacteria.
The most common adverse reactions reported in adults are nausea (11%), vomiting (7%), abdominal pain (6%), gastrointestinal hemorrhage (4%), anemia (2%) and neutropenia (2%).
The most common adverse reactions in pediatric patients are pyrexia (13.3%), abdominal pain (8.2%), vomiting (7.1%), diarrhea (7.1%), constipation (5.1%), increased aminotransferases (5.1%) and rash (5.1%).
Among patients receiving DIFICID (fidaxomicin), 33 (5.9%) withdrew from trials as a result of adverse reactions. Vomiting was the primary adverse reaction leading to discontinuation of dosing (incidence of 0.5% for both DIFICID and vancomycin patients).
The safety and effectiveness of DIFICID have not been established in pediatric patients younger than 6 months of age.
The recommended dose for adults is one 200 mg DIFICID tablet orally twice daily for 10 days, with or without food.
The recommended dose for pediatric patients weighing at least 12.5 kg and able to swallow tablets is one 200 mg DIFICID tablet administered orally twice daily for 10 days. If unable to swallow tablets, pediatric patients may be dosed with DIFICID oral suspension based on weight. DIFICID oral suspension should be administered orally twice daily for 10 days.
No dose adjustment is recommended for patients 65 years of age or older.
No dose adjustment is recommended for patients with renal impairment.
No dosage adjustments are recommended when co-administering DIFICID with substrates of P-gp or CYP enzymes.
The impact of hepatic impairment on the pharmacokinetics of DIFICID has not been evaluated; however, because DIFICID and its active metabolite (OP-1118) do not appear to undergo significant hepatic metabolism, elimination of DIFICID and OP-1118 is not expected to be significantly affected by hepatic impairment.
For more than a century, Merck, a leading global biopharmaceutical company known as MSD outside of the United States and Canada, has been inventing for life, bringing forward medicines and vaccines for many of the world’s most challenging diseases. Through our prescription medicines, vaccines, biologic therapies, and animal health products, we work with customers and operate in more than 140 countries to deliver innovative health solutions. We also demonstrate our commitment to increasing access to health care through far-reaching policies, programs, and partnerships. Today, Merck continues to be at the forefront of research to advance the prevention and treatment of diseases that threaten people and communities around the world – including cancer, cardio-metabolic diseases, emerging animal diseases, Alzheimer’s disease and infectious diseases including HIV and Ebola. For more information, visit www.merck.com and connect with us on Twitter, Facebook, Instagram, YouTube, and LinkedIn.
Forward-Looking Statement of Merck & Co., Inc., Kenilworth, N.J., USA
This news release of Merck & Co., Inc., Kenilworth, N.J., USA (the “Company”) includes “forward-looking statements” within the meaning of the safe harbor provisions of the U.S. Private Securities Litigation Reform Act of 1995. These statements are based upon the current beliefs and expectations of the company’s management and are subject to significant risks and uncertainties. There can be no guarantees with respect to pipeline products that the products will receive the necessary regulatory approvals or that they will prove to be commercially successful. If underlying assumptions prove inaccurate or risks or uncertainties materialize, actual results may differ materially from those set forth in the forward-looking statements.
Risks and uncertainties include but are not limited to, general industry conditions and competition; general economic factors, including interest rate and currency exchange rate fluctuations; the impact of pharmaceutical industry regulation and health care legislation in the United States and internationally; global trends toward health care cost containment; technological advances, new products and patents attained by competitors; challenges inherent in new product development, including obtaining regulatory approval; the company’s ability to accurately predict future market conditions; manufacturing difficulties or delays; financial instability of international economies and sovereign risk; dependence on the effectiveness of the company’s patents and other protections for innovative products; and the exposure to litigation, including patent litigation, and/or regulatory actions.
The company undertakes no obligation to publicly update any forward-looking statement, whether as a result of new information, future events or otherwise. Additional factors that could cause results to differ materially from those described in the forward-looking statements can be found in the company’s 2018 Annual Report on Form 10-K and the company’s other filings with the Securities and Exchange Commission (SEC) available at the SEC’s Internet site (www.sec.gov).
C Diff Foundation, a one hundred percent volunteer, world renowned 501(c)(3) not-for-profit organization, has appointed nationally renowned Gastroenterologist, Dr. Paul Feuerstadt as its first Director of Medical Education.
Dr. Feuerstadt said, “It is my honor to accept this position. I have been involved with the C Diff Foundation over the last 4.5 years and I look forward to assisting in the continued growth of the organization and ensuring that forward progress, awareness and education increases under my tenure. I look forward to working with the board and volunteers to increase awareness and funding across the country and around the world to highlight this disease through in person events, social media, and in the press.”
Dr. Feuerstadt has spent his career refining his practice and expertise in C. difficile. He is dedicated to educating the public through his work with this organization.
Additionally, he plans to offer free patient and provider education through the launch of his new educational website, EverythingCdifficile.com. The goal of the site is to provide education through short videos with relevant clinical information for educational purposes. The site provides concise 3-5 minute lectures covering core topics, recent publications and major conferences about C. difficile infection to educate both patients and providers.
Nancy C. Caralla, Founding President, C Diff Foundation, commented: “Dr. Feuerstadt is a pre-eminent doctor in this space. His dedication and donation of his time and energy to this worthy cause has helped so many patients to date. We look forward to his enhanced leadership and knowledge as the organization grows and strengthens through our advocacy in
the C.diff. community. Dr. Feuerstadt’s new role as Director of Medical Education will provide an additional avenue of support to patients, families, caregivers, and healthcare providers through his educational media available on EverythingCdifficile.com. We are grateful for Dr. Feuerstadt’s time and dedication as we continue fighting this debilitating disease worldwide.”
About Dr. Paul Feuerstadt:
His areas of interest Clostridioides difficile infection and ischemic diseases of the gut and in these areas he has presented his research extensively, authored and co-authored many manuscripts, textbook chapters and online modules. Another passion of Dr. Feuerstadt’s is teaching, frequently giving lectures locally, regionally and nationally. He holds a clinical appointment as an Assistant Clinical Professor of Medicine at the Yale University School of Medicine and is a full time attending physician at the Gastroenterology Center of Connecticut seeing patients with a broad spectrum of clinical gastroenterological diseases.
Dr. Feuerstadt attended the Weill Medical College of Cornell University in Manhattan for medical school and completed his residency in internal medicine at New York Presbyterian Hospital/Weill Cornell. His clinical fellowship training was completed at Montefiore Medical Center in the Bronx, New York.