Clostridium difficile Patients on Opioids Fare Much Worse

Maureen Salamon

June 03, 2018

WASHINGTON, DC — More than three-quarters of patients with Clostridium difficile receive opioids when they are hospitalized, which increases the risk for severe disease, longer hospitalization, and higher readmission rates, a new study shows.

"We know opioids slow the gut, and slowing of the gut causes an alteration of microbiome of the gut, which is one big thing that predisposes patients to C difficile," said Monica Chowdhry, MD, from the West Virginia University Health Sciences Center in Charleston.

"We understand that patients with C difficile can have acute pain in the abdomen," she told Medscape Medical News, "but we were surprised to see that opioids can cause prolonged hospitalization and worsening of disease."

"There haven't been many studies on this topic, so we wanted look into it," she said here at Digestive Disease Week 2018.

Chowdhry and her colleagues conducted a retrospective analysis of 209 patients with C difficile in one hospital over a 2-year period. The 161 (77%) patients taking opioids were prescribed the drugs either during or before hospitalization.

Both the opioid and nonopioid groups were about 60% men.

You're not supposed to give opioids, period, to patients with C difficile, so the fact that 77% of patients got them is shocking.

Patients in the opioid group were more likely to experience a severe case of C difficile — defined in accordance with Infectious Disease Society of America guidelines on mild to moderate or severe disease — than those in the nonopioid group (59.2% vs 38.3%).

In addition, mean hospital stay was 63% longer in the opioid group than in the nonopioid group (14.8 vs 9.1 days), and the rate of hospital readmission was higher in the opioid group (38.2% vs 22.2%).

The prevalence of immunosuppression was higher in the opioid group than in the nonopioid group (19.2% vs 12.5%), as was the proportion of patients on chemotherapy (11.8% vs 6.3%). And more patients in the opioid group had stayed overnight in a healthcare facility in the previous 3 months (60% vs 46%).

"Minimizing the use of opioids, if not avoiding them completely, could lead to something as big as preventing prolonged hospitalizations in these patients," Chowdhry explained, "and to better patient care."

But that might be easier said than done, said Birtukan Cinnor, MD, from Minnesota Gastroenterology in Minneapolis. Patients with C difficile might be in so much pain that it would be difficult to deny them opioid treatment, despite the risks, she explained.

"You're not supposed to give opioids, period, to patients with C difficile, so the fact that 77% of patients got them is shocking," she told Medscape Medical News.

"It's interesting to know that the risks in the opioid group are higher because many patients are treated with opioids, and we didn't know anything about this," said Mabel Guzman-Rodriguez, PhD, from Queen's University in Kingston, Canada, who is working to identify the specific bacterial strains in fecal microbiota transplants that will best fight the infection.

"We're trying to better describe the factors around Clostridium infections, and we're probably missing some of them," she told Medscape Medical News.

In Mexico, opioids are not prescribed as often as they are the United States, said Miguel Morales-Arámbula, MD, from Western General Hospital in Guadalajara.

Still, "there is an increase in opioid use in Mexico, and I would be afraid of these consequences" in C difficile patients, he said, adding that he would "take care" when prescribing opioids to these patients.

Chowdhry, Cinnor, Guzman-Rodriguez, and Morales-Arámbula have disclosed no relevant financial relationships.

Digestive Disease Week (DDW) 2018: Abstract Sa1843. Presented June 2, 2018.

Follow Medscape Gastroenterology on Twitter @MedscapeGastro and Maureen Salamon @maureensalamon

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