Outcomes of Clostridium difficile infection in liver transplant patients: A systematic review and meta-analysis

Clostridioides difficile infection (CDI) is a significant healthcare-associated complication, especially for liver transplant (LT) recipients who are at increased risk due to their immuno-suppressed status and antibiotic use. This systematic review and meta-analysis aimed at elucidating the outcomes of CDI in LT recipients.

We adhered to PRISMA guidelines and searched databases including CENTRAL, PubMed, Embase and Scopus until December 2024. Studies included LT recipients with and without CDI. Outcomes were pooled using meta-analytic techniques with risk ratios (RR) for dichotomous data and mean differences for continuous data.

Among 10 included studies (1,216,500 LT recipients; 3.2% with CDI), the primary pooled analysis showed no significant difference in mortality (OR, 1.34; 95% CI, 0.38-4.72; I² = 100%). Sensitivity analyses excluding influential studies showed higher mortality in LT recipients with CDI (OR, 1.87; 95% CI, 1.45-2.41; I² = 43%). Length of stay was longer among LT recipients with CDI (mean difference, 6.00 days; 95% CI, 2.83-9.17; I² = 100%), with sensitivity analysis showing a mean difference of seven days after exclusion of one study (I² = 0%). Elevated model for end-stage liver disease (MELD) scores were significantly higher in CDI cases (mean difference, 2.77; 95% CI, 1.34-4.20), indicating higher disease severity at baseline. Proton pump inhibitor (PPI) use was not significant in the primary pooled analysis (OR, 2.18; 95% CI, 0.29-16.27; I² = 69%) but was significant after sensitivity analysis excluding one study (OR, 5.87; 95% CI, 2.65-13.03; I² = 0%).

In addition to a significant association between PPI use and increased risk of CDI, CDI significantly affects mortality, duration of hospital stays and pre-operative MELD scores in LT recipients, underscoring its impact on post-operative outcomes.