Clostridium difficile infection after lung transplantation: Are we really doing everything possible?

Clostridium difficile infection (CDI) is now the leading cause of healthcare-associated diarrhea in the hospitalized population (1% to 2%). The change in epidemiology of CDI has been dramatic in recent years with an increasing incidence and severity in several countries according to the Centers for Disease Control (CDC)—in fact, the CDC has described CDI as a “global health challenge.” Over the past decade, solid-organ transplant recipients (SOTr) have been identified as a high-risk group. The incidence of CDI in SOTr ranges from 2% to 30%, depending on the organ type, with the greatest incidence in lung transplant recipients (LTr; 7% to 31%). An alarmingly high associated mortality of CDI in LTr (odds ratio 3.02, 95% confidence interval 2.71 to 3.36, p o 0.001) was demonstrated using multivariable regression analysis in a multi-institutional database of 449,000 SOTr with a 2.7% incidence of CDI. Gunderson and colleagues linked early CDI with the development of bronchiolitis obliterans syndrome in a single-center study; however, other outcome data, specifically in LTr with CDI, are currently lacking. After transplantation, diarrhea is a common non-specific symptom that can be caused by various etiologies, including medications and infection. If CDI is the cause, rapid and accurate diagnosis followed by prompt initiation of effective infection control and treatment measures is paramount to its eradication in LTr. In this issue of the journal, Lee and colleagues report on the impact of CDI on LTr in the largest single-center analysis to date. Again, an alarmingly high mortality was found to be associated with CDI in LTr in their study. Mortality correlated with early (o6 months) and late (46 months) CDI. The entire LTr cohort received prophylactic antibiotics, proton-pump inhibitors (PPIs) and immunosuppression as common denomi-