IDSA: C. difficile in Pregnant Women Underscores New Dangers

TORONTO, Oct. 13 -- Infectious disease specialists cited a report of Clostridium difficile disease in healthy young women, some of them pregnant, as a sign of an alarming shift of the infection to the community.

The report at the Infectious Diseases Society of America meeting came from Judith O'Donnell, M.D., of Drexel University in Philadelphia, who described six cases of C. difficile-associated disease in healthy women, one of whom died.

Three of the women were pregnant, another had recently given birth, and two others had recently undergone elective hysterectomy, reported Dr. O'Donnell.

"When we looked back at the records, we hadn't had a single healthy pregnant woman who had complications of C. difficile in the previous year," Dr. O'Donnell said, "but in the first six months of this year we had four."

The observation is "part of the shift (of C. difficile) from the hospital setting to the community," she said.

"In recent years it has really mushroomed, commented Martin Blaser, M.D., of New York University, president of the society. "Now, we're seeing community-acquired C. difficile, which was very infrequent before, and new risk groups seem to be getting it."

The clinical take-home message, said Dr. O'Donnell, is that physicians treating women - and especially those treating pregnant women - should be aware of the danger of community-acquired C. difficile.

"Ob-gyn doctors in particular need to be aware of it," she said, "because it's not been a disease that they've ever really seen very often in any of their patients, let alone in pregnant women."

In a late-breaker poster session, Dr. O'Donnell and colleagues said they could not identify a common source for the infection. All of the women had recent treatment involving antibiotics, although the therapy was relatively minimal, they reported.

Specifically:

• The two who had an elective hysterectomy had been given two doses of perioperative antibiotics.
• Two were in their second trimester of pregnancy, and were admitted with diarrhea after outpatient treatment for bacterial vaginosis.
• One woman was admitted three weeks after a caesarean delivery.
• The final patient was 12 weeks pregnant, and was admitted eight days after laparoscopic cholecystectomy, for which she was given a single antibiotic dose.

Two of the six were sick enough to need intensive care for sepsis, Dr. O'Donnell said.

One required a total colectomy, but continued to have sepsis, and underwent resection of a large portion of ileum. Despite 14 days of therapy, the patient died of complications from C. difficile-associated disease.

In the other intensive care patient, the sepsis resolved after continuous colonic vancomycin infusion, Dr. O'Donnell and colleagues reported.

Dr. O'Donnell said she has no idea why pregnant women might be a target for C. difficile-associated disease. "Pregnant women are generally healthy," she said.

But Dr. Blaser said C. difficile infection requires "changes in the intestinal micro-ecology." One of the biggest - and most well-known -- culprits is antibiotic use, he said.

Even a few doses have been shown to have effects on intestinal flora that can last for years, Dr. Blaser said, although the changes are subclinical.

"Most physicians think that prescribing antibiotics is relatively low-cost," he said. "But cost always depends on context and in the context of an epidemic (of C. difficile), the costs are going up."

And in pregnant women, he said, other factors may come into play. "They very often complain of constipation, which changes the intestinal micro-ecology," he said. As well, he said, pregnant women often have reflux, and may be prescribed proton pump inhibitors.

A recent study by Sandra Dial, M.D., of Montreal's Royal Victoria Hospital, showed that proton pump inhibitor exposure increased the odds of C. difficile-associated disease by a factor of 3.5.

Both factors are "biologically plausible" and could upset women's intestinal flora enough to render them vulnerable to C. difficile-associated disease, Dr. Blaser said.

The CDC reported late last year on community C. difficile cases in several states, including 10 women who were pregnant or had recently delivered.