Infectious Diseases Society of America Emerging Infections Network Report for Query: Recurrent C. difficile Infections (CDI) Overall response rate: 621/1212 (51.2%) physicians responded from 09/26/12 to 11/06/12. Note: Not all respondents answered all questions, so totals for individual questions vary. This survey was sent only to EIN members with an adult infectious diseases practice. Responders as percent of overall members in each category: Region: New England 50 (57% of 87 members) Mid Atlantic 93 (50% of 186 members) East North Central 95 (54% of 177 members) West North Central 61 (54% of 112 members) South Atlantic 108 (49% of 220 members) East South Central 28 (50% of 56 members) West South Central 33 (41% of 80 members) Mountain 40 (58% of 69 members) Pacific 105 (52% of 203 members) Puerto Rico 1 (20% of 5 members) Canada 7 (39% of 18 members) Years experience since ID fellowship: <5 years 129 (43% of 302 members) 5-14 154 (44% of 350 members) 15-24 177 (61% of 288 members) 25 161 (59% of 273 members) Employment: Hospital/clinic 175 (52% of 334 members) Private/group practice 212 (53% of 399 members) University/medical school 183 (46% of 394 members) VA and military 45 (58% of 78 members) State gov t 6 (75% of 8 members) Primary hospital type: Community Non-university teaching University VA hospital or DOD City/county Other 181 (50% of 365 members) 190 (54% of 349 members) 173 (47% of 366 members) 46 (57% of 81 members) 21 (55% of 38 members) 10 (71% of 14 members) *Respondents were significantly more likely than non-respondents to have at least 15 years of ID experience (p<0.0001). Page 1
Question 1. Estimated number of patients with CDI treated in the last 6 months sorted by the number of those patients having at least one relapse of CDI. [602 respondents] Pts with CDI Pts with recurrent CDI Number (%) None None 64* (11%) 1-10 None 16 (3%) 1-4 145 (24%) 5-10 16 (3%) 11-25 None 6 (1%) 1-4 74 (12%) 5-10 117 (19%) 11-25 18 (3%) 26-50 None 0 1-4 10 (2%) 5-10 49 (8%) 11-25 42 (7%) >25 8 (1%) >50 None 0 1-4 0 5-10 5 (0.8%) 11-25 21 (3%) >25 11 (2%) *The 64 members who responded that they do not treat CDI are not included in further analyses Question 2. Treatment choices for the following CDI indications [column percentages shown]: [Instructions were to select all that apply; numbers add to more than 100%] Primary episode mild disease 1 st relapse mild disease 2 nd relapse mild disease Number of respondents 537 536 529 Oral metronidazole 449* (84%) 215 (40%) 17 (3%) Oral vancomycin 87 (16%) 347 (65%) 282 (53%) Fidaxomicin 1 (0.2%) 20 (4%) 60 (11%) Oral vancomycin taper -- 79 (15%) 290 (55%) Rifaximin chaser -- 9 (2%) 73 (14%) Nitazoxanide -- 1 (0.2%) 10 (2%) Tigecycline -- 1 (0.2%) 3 (0.6%) Any form of vancomycin 87 (16%) 364 (68%) 495 (94%) chosen (oral course or taper) Combination therapy ( 2) -- 127 (24%) 121 (23%) *235 (52%) of the 449 respondents who initially chose oral metronidazole switched to another agent for the first relapse. 85 (98%) of the 87 respondents who initially chose oral vancomycin continued with vancomycin ± another agent; one respondent switched to oral metronidazole; one switched to fidaxomicin. Page 2
Duration of treatment for second relapse, mild disease: [285 respondents] 10-14 days 122 (43%) 15-28 days 82 (29%) 29-56 days 68 (24%) >56 days 13 (4%) Question 3. For a third (or subsequent) relapse, would your treatment choices change from above? No 143 (27%) Yes 392 (73%) If yes, how? The following treatment choices were mentioned in this open text field: Vancomycin pulse and/or taper and/or longer course mentioned 190 times Fidaxomicin mentioned 119 times Rifaximin mentioned 72 times FMT mentioned 70 times IVIG mentioned 9 times Nitazoxanide mentioned 5 times Question 4a. Does your institution offer testing for the NAP1 (BI/027) strain? Not sure 39 (7%) No 365 (68%) Yes 134 (25%) Question 4b. Would your treatment choices change if your patient was known to carry the NAP1 strain? Not sure 153 (28%) No 225 (42%) Yes 160 (30%) Question 5. Treatment choices for the following CDI indications [column percentages shown]: [Instructions were to select all that apply; numbers add to more than 100%] [533 respondents] Severe disease without ileus Severe disease with ileus Oral metronidazole 30 (6%) 12 (2%) Oral vancomycin 514 (96%) 327 (61%) IV metronidazole 252 (47%) 481 (90%) Vancomycin per rectum 57 (11%) 365 (68%) Fidaxomicin 30 (6%) 31 (6%) Rifaximin 20 (4%) 13 (2%) Tigecycline 18 (3%) 53 (10%) ---Oral vancomycin alone selected by the single largest group of respondents (N=224, 42%) for severe disease without ileus ---The combination of oral vancomycin, intravenous metronidazole and vancomycin per rectum was chosen by the single largest group of respondents (N=160, 30%) for severe disease with ileus Page 3
Question 6. Have you ever used/recommended IVIG in the treatment of patients with CDI? No 264 (49%) Yes 274 (51%) If yes, how many times? <5 times 211 (77%) 5-10 times 42 (16%) >10 times 19 (7%) Question 7. Do you recommend probiotics (including Saccharomyces boulardii) for: management of current CDI? prevention of CDI (pt on antibiotics) No 243 (46%) 268 (50%) Yes, rarely 79 (15%) 80 (15%) Yes, occasionally 121 (23%) 120 (23%) Yes, routinely 91 (17%) 64 (12%) Question 8. Circumstances under which you would recommend Fecal Microbiota Transplantation (FMT): [Select all that apply; numbers add to more than 100%] [527 respondents] No circumstances/would not recommend 47 (9%) Recurrent disease 424 (80%) Severe disease 125 (24%) Other 54 (10%) If FMT recommended for recurrent disease, after how many relapses? [406 respondents] One 9 (2%) Two 94 (23%) Three 165 (41%) Four 53 (13%) Five 31 (8%) Six 5 (1%) Eight 2 (0.5%) Range typed in as from one to three 10 (2%) Range typed in as from four to eight 21 (5%) Typed in as depends or arbitrary 2 (0.5%) Typed in as multiple or several 14 (3%) Question 9. Is FMT currently available in your primary institution? No 249 (47%) Not yet but we are working on it 127 (24%) Yes 156 (29%) Page 4
Question 10. If FMT is not available in your institution, why not? [Instructions were to select all that apply; numbers add to more than 100%] [330 respondents] Patient refusal 15 (5%) Compensation/reimbursement issues 84 (26%) Complexity/costs of donor testing 147 (45%) Logistics of FMT preparation and delivery 265 (80%) Other* 41 (12%) *In open text field, other barriers mentioned included: Haven t needed it /No requests for it by 19, IRB approval/legal issues by 16, Conflicts/issues with Gastroenterology by 15, Available at nearby hospital by 11; Hospital administration barriers/resistance by 9. Question 11. Have you observed any transmissible diseases or other complications that have been associated with FMT? [488 respondents] Not sure 83 (17%) No 402 (82%) Yes* 3 (0.6%) *Recurrence of CDI after transplant (N=2); HIV/hepatitis B & C (N=1) Fecal Microbiota Transplantation (FMT) Subsurvey N=149 respondents Question 1. How many patients under your care have receive FMT in the past year? None, but others in my institution/group provide FMT 42 (28%) 1-4 79 (53%) 5-10 22 (15%) 11-25 4 (3%) >25 2 (1%) Question 2. What labs do you recommend for the FMT donors? [Instructions were to select all that apply; numbers add to more than 100%] [144 respondents] None 6 (4%) HIV 126 (88%) Hepatitis B 123 (85%) Hepatitis C 113 (78%) Hepatitis A 107 (74%) Stool for C. difficile 105 (73%) Stool culture 100 (69%) Stool for O&P 94 (65%) RPR 80 (56%) CMV 19 (13%) Other 11 (8%) Page 5
Question 3. How is FMT usually administered? NG tube / nasojejunal tube 47 (33%) Enema 27 (19%) Colonoscopy 69 (48%) Question 4. What is the usual source of the donated material? Family/household member 141 (98%) Donor pool (fresh) 0 Frozen, banked material 3 (2%) Question 5. How many instillations are usual for each patient receiving FMT? Single instillation 125 (91%) Multiple instillations 12 (9%) Question 6. What is your usual volume range per instillation? <100 ml 23 (20%) 100-249 ml 53 (47%) 250-500 ml 30 (27%) 501-1000 ml 7 (6%) >1000 ml 0 Question 7. What is your estimated success rate with FMT? <50% 2 (2%) 50-79% 19 (15%) 80-95% 48 (38%) >95% 56 (45%) Page 6