The incidence in our collective is with 1,6% high compared to data in literature. Reichardt et al. describes an incidence of 0,1% for Europe and an incidence of 0,1% to 2% for the USA . Heinlen et al. could found an incidence of 0,6% for the USA in the year 2003 .
Especially the patients with head and neck cancer have a high risk of developing CDAD. This might be due to a multitude of risk factors. 19/34 of our patients were suffering from a squamous cell carcinoma of the head and neck (SCCHN).
Chemoradiation is a standard treatment for different carcinomas [[17, 29–31]]. Many patients on radiooncological wards have at least this as a major risk factor [[16, 17, 32]]. Some of these patients develop Neutropenia and are therefore immunocompromised [18, 19].
Several underlying diseases, mainly a reduced general condition and compromised immune function have been described as risk factors to develop CDAD [1, 11].
Hospitalized radiooncological patients often need an antibiotic or antimycotic medication during radiotherapy [21, 22]. Beside those risk factors, the frequency of a treatment with proton pump inhibitor is estimated to be quiet high on radiooncological wards. Tube feeding and parenteral nutrition favour the onset of CDAD [[3, 33, 34]].
Especially head and neck cancer patients have a high rate of dysphagia . Nearly all patients having a dysphagia of CTC grade II or higher requiring tube feeding or parenteral nutrition [20, 35]. Wolff et al. found a rate of dysphagia in head and neck tumour patients of 77% and a rate of Grad 3 leukopenia or higher of 11% . In our collective all head and neck cancer patients but 3 were addicted to tube feeding or parenteral nutrition (18/21).
There are data identifying underlying diseases of the gastrointestinal tract to be risk factors for CDAD [2, 3]. Whether abdominal or pelvine radiotherapy triggers CDAD is not known. In our collective only one patient received abdominal and five patients received pelvic radiotherapy.
Some data give evidence that haematological and oncological patients are patients at risk for developing CDAD [[12–14]]. Most data exist for paediatric oncological units and for bone marrow transplant units [[12, 15, 36, 37]]. In the reports on haematology-oncology patients, that include patients undergoing radiotherapy, no subgroup analysis was done for that collective of patients . In summary there are no data about the risk for radiooncological patients suffering from CDAD.
Our data confirm the assumption that radiooncological patients are also patients at risk for an infection with clostridium difficile.
Several authors have shown a decrease in local control for different tumours due to unplanned interruptions of radiotherapy [38, 39]. Bese et al. reported a decrease of 1.4% per day of unplanned interruption for head and neck carcinomas. SCCHN are common in our collective and often have an interruption of radiotherapy.
42% of the patients developing a CDAD need a pause of the radiation. For those patients who have an interruption of the radiotherapy, the average interruption time is ten days. A decrease of loco regional control of 10 to 12% for one week of interruption has been reported [38, 40].
Beside interruption of radiotherapy patients suffering from CDAD have several additional factors decreasing the feasibility of the oncological treatment like weight loss, incomplete chemotherapy and a decrease of general condition.
For bronchial carcinoma, studies have emphasized the importance of prolonged overall treatment time. One study suspected an increase of the risk of death of 2% even for a one day break . A statistically significant decrease in overall survival for patients receiving a radiochemotherapy for SCLC could be found .
Beside bronchial carcinoma and head and neck cancer, also for cervical carcinoma, anal cancer and several other carcinomas it has been reported that prolongation of overall treatment time and interruption of radiotherapy decreases the loco regional control . For that reason, a CDAD is a serious problem for patients undergoing radiotherapy.
Also the feasibility of chemotherapy concomitant to radiotherapy is important for loco regional control and overall survival . Several authors suspect the cumulative dose of concomitant chemotherapy to be an important prognostic factor [43, 44]. If you compare the feasibility of chemotherapy in our collective with data in literature, you can find a low cumulative dose for the patients with CDAD .
In our collective only 19% of the patients received the complete chemotherapy dose. For example of the patients receiving Cisplatin only 3 of 13 patients received at least 200 mg/m2 Cisplatin. The poor feasibility of chemotherapy in our collective might decrease the loco regional control and overall survival for patients suffering from a CDAD.
In summary with four patients dying due to CDAD, a change from a curative to a palliative concept in another four patients, CDAD is a severe problem for radiooncological patients. Compared with the lethality of 0,5% to 2% described in literature the 11,8% in our collective (four out of 34 patients) seems to be very high . This might be due to a negative selection of the patients. The average age is high and patients had a high number of risk factors, concomitant diseases and often a reduced general condition.
There are several options reducing the risk of developing CDAD. Beside the restrictive use of antibiotics and proton pump inhibitors, the upkeep of oral nutrition as long as possible is essential in reducing the rate of CDAD. Especially Moxifloxacin, which is known to trigger CDAD, was not used since 2008 in clinical routine [7, 45]. The high rate of patients in our collective receiving Moxifloxacin until 2007 and the decreasing incidence of CDAD since 2008 seemed to be an effect of discontinuing Moxifloxacin in clinical use.
With these arrangements and an intensive screening for Clostridium difficile the rate of infections has declined from 16 cases in 2007 to 11 in 2008, 4 in 2009 and 2 in 2010.
Even though there is only little evidence in probiotics reducing the rate of CDAD for patients at risk, we treated all patients with four or more risk factors frequently [[28, 46–49]].