Clostridium difficile Infection in the Inflammatory Bowel Disease Patient

Abstract

Clostridium difficile infection (CDI) has been increasing in frequency and severity in patients with inflammatory bowel disease (IBD). Population based and single center studies have shown worse clinical outcomes in concomitant CDI and IBD, with several reporting longer length of hospital stay, higher colectomy rates and increased mortality. Clinically, CDI may be difficult to distinguish from an IBD flare and may range from an asymptomatic carrier state to severe life threatening colitis. The traditional risk factors for CDI have included hospitalization, antibiotic use, older age and severe co-morbid disease but IBD patients have several distinct characteristics including younger age, community acquisition, lack of antibiotic exposure, colonic IBD and steroid use. CDI can occur in the small bowel and specifically in ulcerative colitis patients who have had a colectomy and an ileal pouch anal anastomosis. PCR based assays and combination Elisa algorithms have improved the sensitivity and specificity of testing, though in IBD patients have raised clinical questions about how to best manage diarrhea in the setting of possible C. difficile colonization. Treatment modalities for CDI have not been examined in randomized clinical trials in the IBD population. Newer antibiotics, immunotherapy and fecal microbiota transplantation may alter current treatment strategies. This review will focus on the unique epidemiology of CDI in IBD patients, detail clinical disease states, and provide updated diagnostic strategies, prevention and treatment options.

Clostridium difficile infection and inflammatory bowel disease

“…EIA for C. difficile toxins A and B is rapid (results are available within a few hours), inexpensive, and widely available, being used as routine test in most countries (21). Testing should include both toxin A and B because some C. difficile strains produce only toxin A or B. EIA sensitivity for toxins A and B is 60%-94%, with 75%-100% specificity.…”

“…Due to the high prevalence of CDI in IBD patients and clinical/laboratory similarity between CDI and IBD exacerbation, it is recommended that all IBD patients with a disease flare should be tested for C. difficile (14)(15)(16)(18)(19)(20)(21). There is no indication for post-treatment testing to confirm cure.…”

“…CDI was first associated with IBD in the early 1980s (13), but was somehow neglected until ten years ago, when several studies and reviews clearly demonstrated that patients with one of the two major forms of IBD (ulcerative colitis-UC; Crohn's disease-CD) are at high-risk for CDI (8)(9)(10)(11)(12)(14)(15)(16)(17)(18)(19)(20)(21). Besides the well-known risk factors for CDI in non-IBD population, there are some typical IBD-related risk fac-EPIDEMIOLOGY Both single-center studies (8,9,22,27,(29)(30)(31) and large nationwide data analyses (9,11,12,26) have independently reported an increased CDI incidence among IBD patients.…”

Clostridium difficile Infection in Pediatric Inflammatory Bowel Disease Patients in the Era of Molecular Diagnostics and Advanced Therapeutics

“…An increased prevalence of Clostridium difficile infection (CDI) in pediatric Inflammatory Bowel Disease (IBD) has been reported in various studies (1)(2)(3), primarily diagnosed by stool toxin assay (1,4). Although some risk factors for CDI have been reported consistently in adult IBD study including recent antibiotic use and recurrent hospitalizations (5), there are no consistent risk factors reported in pediatric studies.…”

FMT in IBD: What Have We Learned?

“…Testing for C. difficile in IBD patients with symptoms of disease flare is considered a standard-of-care [13]. One particular strength of this study was the methods used to diagnose CDI in these patients.…”