Background: Guidelines on the treatment of Clostridioides (Clostridium) difficile infection (CDI) have historically recommended avoiding antimotility agents (AAs) in patients with active CDI based on theoretical concerns that administration of AAs may precipitate serious adverse events such as toxic megacolon in these patients. These recommendations, however, are based on limited and conflicting data. We previously reported preliminary data suggesting the potential safety of AAs in patients with CDI. The current study builds on our prior work using a larger, more robust dataset to describe the use of AAs and adverse gastrointestinal events in patients hospitalized on the malignant hematology service who developed CDI.
Methods: We used the electronic health record of a 600-bed academic teaching hospital to identify all inpatients on the malignant hematology service from April 21, 2012 through September 21, 2017 with one or more positive C. difficile stool toxin assays during their admission. We assessed for administration of AAs (loperamide, atropine/diphenoxylate, or opium) within 14 days after CDI diagnosis as well as for any subsequent adverse gastrointestinal events (toxic megacolon, ileus, or bowel obstruction) during the admission by ICD-10 codes. We then manually reviewed all cases of CDI in which an adverse event occurred to determine whether the event occurred within 72 hours after AA administration. Multivariable logistic regression was used to assess the association of adverse events with AAs, adjusting for the propensity to receive AAs, patient characteristics, and markers of disease severity.
Results: We identified 350 patients with CDI, all but 3 of whom received appropriate antibiotic treatment for CDI. AAs were used in 27% of cases, or 95 patients total (Table 1). The risk of adverse events did not differ between patients who received AAs and those who did not (2.1% vs. 2.0%, adjusted odds ratio 0.45 [95% CI: 0.08 – 2.70]). Patients who received AAs had more days of diarrhea (4.94 vs. 2.20, p < 0.001), though this was not significant in the adjusted analysis (relative risk 1.14 [0.94 - 1.37]). There were no significant differences in the number of fluid boluses given, the total volume of IV fluid given, or the number of wound care consults in adjusted or unadjusted analyses (Table 2).
Conclusions: AAs were administered to 27% of patients in the first 14 days after CDI diagnosis and were not associated with a significantly increased risk of gastrointestinal adverse events. This evidence suggests that it may be safe to use AAs in malignant hematology inpatients who are being treated for CDI.
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