Objective:

To formulate recommendations for the management of Clostridioides difficile infection (CDI) among patients with hematological malignancies (HM). To document current practices for Clostridioides difficile infection (CDI) management in patients with hematological malignancies (HM) and identify areas of unmet need preceding development of ECIL-10 recommendations.

Approach:

• Expert Survey: An online survey was distributed to European Conference on Infections in Leukemia members to assess CDI epidemiology, severity criteria, diagnostic practices, and therapeutic approaches in patients with HM.
• Respondents: Forty-nine of 61 experts (80%) from different centers responded, representing 18 European countries as well as the United States, Brazil, Turkey, and Israel.
• Clinical Scope: The survey assessed CDI incidence, diagnostic testing, severity definitions, first-line and recurrent CDI treatment, treatment duration, and use of fecal microbiota transplantation and other recurrence-prevention strategies.

Key Findings:

• Among centers reporting adult CDI rates, 46% reported an incidence of 5% to 10%, while overall CDI incidence was below 10% in more than 85% of surveyed centers.
• At diarrhea onset, 86% of centers routinely tested for C. difficile and other enteric pathogens.
• Conventional severity criteria were considered difficult to apply in patients with HM; leukocytosis and hypoalbuminemia were viewed as the least useful criteria, while severe diarrhea and severe abdominal pain were commonly used.
• Vancomycin was the most frequently reported first-line therapy for nonsevere CDI, identified in 65% of responses.
• Fidaxomicin was the preferred treatment for first recurrence, particularly when the initial episode had been treated with vancomycin, and was also preferred for second or later recurrence.
• For second or later recurrence, 31% of centers reported use of fecal microbiota transplantation.
• Most centers used the standard 10-day CDI treatment course.

Interpretation:

Patients with HM require specific severity-assessment criteria for CDI, as conventional criteria may not apply due to unique clinical factors. The survey identified substantial variation in CDI diagnosis, severity assessment, and treatment among patients with hematological malignancies. Standard severity criteria used in the general population may be less applicable in this setting because factors such as neutropenia, leukocytosis, hypoalbuminemia, and fever can be affected by the underlying malignancy or its treatment. The findings highlight the need for HM-specific severity criteria and optimization of available CDI therapies.

Limitations:

• The survey included a relatively small number of experts and centers.
• Survey findings may have limited generalizability and may not reflect practices outside tertiary care centers.
• The analysis did not include patient-level data.
• Self-report and selection biases may have influenced the findings.
• Definitions of treatment failure and approaches to recurrence management varied across centers.

Conclusion:

The findings indicate the need for tailored approaches to CDI management in patients with hematological malignancies. The survey identified discrepancies in CDI management among patients with hematological malignancies and highlighted several unmet needs, including better-defined severity criteria, optimization of the use and duration of available treatments, access to intravenous therapies for patients unable to take oral medication, and further evaluation of microbiome-based therapies.

Sources:

• Management of Clostridioides difficile infections in patients with hematological malignancies – a survey by European Conference on Infections in Leukemia (ECIL) and Infectious Diseases Working Party (IDWP) of The European Society for Blood and Marrow Transplantation (EBMT)