Clostridioides difficile infection in rifampin-sensitive pulmonary tuberculosis: a retrospective comparative study

Background Clostridioides difficile infection (CDI) is an important cause of hospital-acquired diarrhea but remains poorly characterized during tuberculosis treatment. Patients with pulmonary tuberculosis may be particularly vulnerable because of prolonged treatment, hospitalization, comorbidities, proton pump inhibitor (PPI) exposure, and treatment-related disruption of the intestinal microbiota. Objective This study aimed to characterize CDI in patients with rifampin-sensitive pulmonary tuberculosis and explore clinical factors associated with its occurrence. Methods This retrospective comparative study included 30 adults hospitalized with rifampin-sensitive pulmonary tuberculosis between June 2024 and January 2025 at a tertiary infectious disease hospital in western China. Ten patients with clinically diagnosed, PCR-positive CDI were compared with 20 contemporaneous tuberculosis patients without CDI. Demographic characteristics, clinical manifestations, laboratory parameters, medication exposure, and in-hospital outcomes were extracted from medical records. Group comparisons and exploratory multivariable logistic regression were performed to identify factors associated with CDI. Results Patients with CDI had significantly lower body mass index (P = 0.009), mean corpuscular volume (P = 0.014), and serum albumin levels (P = 0.041) than those without CDI. Other hematological, inflammatory, hepatic, and renal parameters were generally comparable between groups. None of the three significant variables remained independently associated with CDI in multivariable analysis. PPI exposure was common among patients with CDI, with nine of ten having received PPIs for at least two weeks during anti-tuberculosis treatment. Seven patients with CDI improved during hospitalization, two were transferred to higher-level hospitals, and one died. Conclusion CDI represents an important diagnostic consideration in patients with rifampin-sensitive pulmonary tuberculosis who develop gastrointestinal symptoms during treatment. Lower BMI, MCV, and serum albumin characterized patients with CDI but were not independently associated with infection after adjustment. These findings highlight the importance of clinical vigilance and timely CDI testing in this population.