The impact of corticosteroid use on inpatients with inflammatory bowel disease and positive polymerase chain reaction for Clostridium difficile

Abstract

Background/Aims Optimal management of inflammatory bowel disease (IBD) with concomitant Clostridium difficile infection (CDI) is controversial, especially when CDI diagnosis is made by polymerase chain reaction (PCR) testing, which may reflect colonization without infection. Methods We performed a multicenter review of all inpatients with IBD and PCR diagnosed CDI. Outcomes included length of stay, 30- and 90-day readmission, colectomy during admission and within 3 months, intensive care unit (ICU) admission, CDI relapse and death for patients who received corticosteroid (CS) after CDI diagnosis versus those that did not. Propensity-adjusted regression analysis of outcomes based on CS usage was performed. Results We identified 177 IBD patients with CDI, 112 ulcerative colitis and 65 Crohn’s disease. For IBD overall, CS after CDI diagnosis was associated with prolonged hospitalization (5.5 days: 95% confidence interval [CI], 1.5–9.6 days; P =0.008), higher colectomy rate within 3 months (odds ratio [OR], 5.5; 95% CI, 1.1–28.2; P =0.042) and more frequent ICU admissions (OR, 7.8; 95% CI, 1.5–41.6; P =0.017) versus no CS. CS use post-CDI diagnosis in UC patients was associated with prolonged hospitalization (6.2 days: 95% CI, 0.4– 12.0 days; P =0.036) and more frequent ICU admissions (OR, 7.4; 95% CI, 1.1–48.7; P =0.036). Conclusions CS use among IBD inpatients with CDI diagnosed by PCR is associated with poorer outcomes and would seem to reinforce the importance of C. difficile toxin assay to help distinguish colonization from infection. This adverse effect appears more prominent among those with UC.

Targeting Clostridioides difficile Infection-Induced Inflammation to Improve Treatment Outcome

“…Pretreating mice with anti-TNF-α monoclonal antibodies was associated with more severe histopathology of the colon relative to untreated mice [30]. In addition, NSAIDs, H2-receptor blockers and steroids have all been associated with higher risk of CDI in several retrospective studies [16][17][18][19][30][31][32][33][34]. Notably, several other studies demonstrated no correlation between the aforementioned drugs and the development of CDI [35][36][37].…”

“…In addition, a beneficial outcome other hand, inflammation was found to play an important role in the primary protection against CDI and hence suppressing the inflammation through the use of antiinflammatory drugs has been considered a risk factor for CDI [13][14][15]. Therefore, several non-steroidal antiinflammatory drugs (NSAIDs), antihistamines and corticosteroids were associated with higher risk of CDI [15][16][17][18][19]. Experimentally, NSAID-(indomethacin-) pretreated mice had an exaggerated CDI [20].…”

The Current Knowledge on Clostridioides difficile Infection in Patients with Inflammatory Bowel Diseases

“…A combination of two or three immunomodulators was associated with negative outcomes on multivariate analysis [ 146 ]. In a study performed by Lim et al, corticosteroids use following CDI diagnosis by PCR in UC-hospitalized patients was associated with an increased length of hospitalization, higher ICU admission and colectomy rate [ 147 ]. In another retrospective analysis, corticosteroid escalation in CDI-IBD was associated with a higher risk of colon surgery within one year of CDI, while immunomodulator and biologic therapy changes did not influence the outcomes [ 148 ].…”

Korean Association for the Study of Intestinal Diseases guidance for clinical practice of adult inflammatory bowel disease during the coronavirus disease 2019 pandemic: expert consensus statements

“…Thirty-seven patients (7%) progressed to severe disease, and old age, 2 or more comorbid underlying diseases, and systemic corticosteroid use were identified as risk factors [ 18 ]. Because high-dose corticosteroids increase the risk of respiratory and opportunistic infections in IBD patients [ 61 , 62 ], the BSG guidelines recommend rapid dose reduction (10 mg/wk) if possible [ 34 ]. The Asian Pacific Association of Gastroenterology (APAGE) recommends that dose reduction be considered in patients on prednisolone > 20 mg per day, depending on disease activity.…”