Evaluating Disparities in Recurrent Clostridioides difficile Infection (CDI) and Fecal Microbiota Transplant (FMT) Treatment using Geospatial and Social Vulnerability Analytic Tools Open Access

Abstract

Recurrence of Clostridioides difficile infection (CDI) occurs in 20-30% of patients and is associated with increased risk of complications and mortality. Fecal microbiota transplantation (FMT) is the most definitive treatment for recurrent CDI. Predictors of recurrent CDI have identified patient race as important, but disparities of CDI incidence and subsequent health outcomes are more complicated than just race alone. We aimed to estimate the magnitude of any racial disparities in the incidence of recurrent CDI and treatment with FMT and determine if specific metrics of social vulnerability better predict these events than race alone. The study population consisted of patients ages 18+ located within Health District 3 with at least one incident episode of CDI between 2016 and 2019. Although black race was found to be protective of patients developing multiple recurrences of CDI, the only SVI theme that was predictive of any recurrence was housing type & transportation. Black race, as well as all SVI themes were significant predictors of FMT receipt in a univariate logistic regression, with leading themes including socioeconomic status and racial & ethnic minority status. Adjusting for age, gender, and racial & ethnic minority status, patients located in vulnerable census tracts were 44% less likely to receive an FMT compared to the rest of the study population (p-value = 0.002). Geospatial analysis comparing the number of FMTs and rCDI rates by census tract suggests disproportionate use of FMTs in HD3.

Table of Contents

Background

Methods

Results

Discussion

Conclusion

References

Tables

Table 1. Summary of Social Vulnerability Index (SVI) themes.

Table 2. Characteristics of overall study population by CDI history.

Table 3. Social Vulnerability Index (SVI) themes as a predictor for rrCDI¹

Table 4. Characteristics of overall study population, by FMT receipt.

Table 5. Distribution of SVI themes, stratified by FMT receipt. Restricted to patients with at least one rapid recurrent episode (FMT eligible).

Table 6. Multivariate analysis predicting FMT receipt. Restricted to patients with at least one rapid recurrent episode (FMT eligible). n=2374

Table 7. Statistical Significance of each SVI Theme as an independent predictor¹ of FMT receipt in forward selection process by scenario with and without including Race as an eligible predictor. Restricted to patients with at least one rapid recurrent episode (FMT eligible); n=23742

Table 8. Multivariate analysis predicting FMT receipt. Restricted to patients with at least one rapid recurrent episode (FMT eligible). n=3038

Table 9. Multivariate analysis including uninsured variable predicting FMT receipt. Restricted to patients with at least one rapid recurrent episode (FMT eligible). n=3038

Figures

Figure 1. Spot map of number of Fecal Microbiota Transplantation (FMTs) by census tract of recipients residence; HD3, 2016-2019

Figure 2. Choropleth map of (A) CDI rate (episodes of CDI per 100,000 persons) and (B) recurrent CDI rate (recurrent CDI episodes per 100,000 persons) by census tract; HD3, 2016-2019

Figure 3. Geographical distribution of each SVI theme in HD3 by census tract.  0=least vulnerable, 1=most vulnerable.

Figure 4. Geographical distribution of the composite SVI theme in HD3 by census tract.  0=least vulnerable, 1=most vulnerable.

Figure 5. Predominant SVI theme by census tract in HD3.

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Epidemiology - MPH & MSPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Keyword	c. difficile social vulnerability index geospatial fecal microbiota transplant disparities recurrence
Committee Chair / Thesis Advisor	Scott Fridkin, Emory University

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