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Clostridium Difficile is associated with High Mortality among Cirrhotics in India
Vadivukkarasi Thangaraju Jayalakshmi1, Shalini Anandan2, Uday George Zachariah1, Ashish Goel1, Balaji Veeraraghavan2, Sajith Kattiparambil1, CE Eapen1
1Department of Hepatology (Division of GI Sciences), 2Department of Microbiology, Christian Medical College, Vellore, Tamil Nadu, India.

Corresponding Author
Prof. C.E. Eapen


Background: To assess the prevalence and impact of Clostridium difficile infection (CDI) in hospitalized patients with cirrhosis in India.
Methods: In this prospective observational study from June 2015 to March 2016, all hospitalized patients with cirrhosis and acute diarrhea at the time of admission or during hospitalization were included. We studied hospitalized patients with cirrhosis without diarrhea during the same period to detect asymptomatic colonizers.Stool samples were tested for CDI, bacterial cultures, and parasite microscopy in patients with diarrhea.CDI was detected using a stool PCR test that detects the pathogenicity locus of toxigenic Clostridium difficile gene. We analysed the impact of CDI on hospital outcomes and also assessed the risk factors for acquiring CDI.
Result: Among 92 hospitalized cirrhotic patients with acute diarrhea [male: 74; median age: 50 (range 19 to 80) years; Child’s class A: B: C: 8:41:43; median MELD score: 18 (range 6 to 44)], 6 (6.5%) had CDI by positive stool PCR. Use of antibiotics (100% CDI Vs 55.8% non-CDI, p= 0.04) and steroids (50% CDI vs 10.5% non-CDI, p =0.028) emerged as risk factors for CDI among cirrhosis patients. Two of the 6 patients (33.3%) with CDI as compared to 6/86 patients (7%) with no CDI died (p-value: 0.08).There were no asymptomatic colonizers amongst 35 hospitalized cirrhosis patients without diarrhea.Conclusions: C. difficile, although uncommon, was an important cause of mortality in cirrhosis patients hospitalized with diarrhea in India.Prior use of antibiotics or steroids were identified as risk factors for CDI.