Clostridium difficile infection and inflammatory bowel disease: Understanding the evolving relationship

Preoperative Clostridium difficile infection is not associated with an increased risk for the infection in ileal pouch patients

BACKGROUND

Clostridium difficile infection (CDI) might contribute to a refractory course of pouchitis. However, the association between preoperative CDI and postoperative CDI in ileal pouch patients has not been investigated.

AIM

Our study aimed to evaluate whether preoperative CDI had an impact on the occurrence of postoperative CDI in pouch patients.

METHODS

Consecutive eligible ileal pouch patients from February 2005 to December 2012 were identified from the Pouchitis Registry at the Cleveland Clinic. Patients in the registry with known status of CDI of the pouch were surveyed with a structured questionnaire regarding preoperative C. difficile test and its treatment. Medical records were also reviewed. Demographics and clinical characteristics and outcomes were evaluated with univariable and multivariable analyses.

RESULTS

A total of 102 patients with preoperative C. difficile test were identified for this study and 21 patients (20.6%) tested positive for C. difficile test after colectomy. In logistic regression analysis, male patients were 7.85 (P = 0.003) times more likely to have CDI than women. In addition, preoperative significant comorbidities (P = 0.037) and preoperative use antibiotics for other indications (P = 0.005) were found to be associated with postoperative CDI of the pouch. However, there was no evidence to suggest that the preoperative CDI was associated with the occurrence of postoperative CDI (P = 0.769).

CONCLUSIONS

Postoperative CDI occurred frequently in male patients with IPAA. In addition, preoperative comorbidities and antibiotic use were found to be risk factors for CDI of the pouch. However, preoperative CDI did not appear to be associated with an increased risk for postoperative CDI in pouch patients.

Epidemiology of Clostridium difficile infection

There has been dramatic change in the epidemiology of Clostridium difficile infection (CDI) since the turn of the 21st century noted by a marked increase in incidence and severity, occurring at a disproportionately higher frequency in older patients. Historically considered a nosocomial infection associated with antibiotic exposure, CDI has now also emerged in the community in populations previously considered low risk. Emerging risk factors and disease recurrence represent continued challenges in the management of CDI. The increased incidence and severity associated with CDI has coincided with the emergence and rapid spread of a previously rare strain, ribotype 027. Recent data from the United States and Europe suggest that the incidence of CDI may have reached a crescendo in the recent years and is perhaps beginning to plateau. The acute care direct costs of CDI were estimated to be US$4.8 billion in 2008. However, nearly all the published studies have focused on CDI diagnosed and treated in the acute care hospital setting and fail to measure the burden outside the hospital, including recently discharged patients, outpatients, and those in long-term care facilities. Enhanced surveillance methods are needed to monitor the incidence, to identify populations at risk, and to characterize the molecular epidemiology of strains causing CDI.

Microbiota dynamics in patients treated with fecal microbiota transplantation for recurrent Clostridium difficile infection

Clostridium difficile causes antibiotic-associated diarrhea and pseudomembraneous colitis and is responsible for a large and increasing fraction of hospital-acquired infections. Fecal microbiota transplantation (FMT) is an alternate treatment option for recurrent C. difficile infection (RCDI) refractory to antibiotic therapy. It has recently been discussed favorably in the clinical and scientific communities and is receiving increasing public attention. However, short- and long-term health consequences of FMT remain a concern, as the effects of the transplanted microbiota on the patient remain unknown. To shed light on microbial events associated with RCDI and treatment by FMT, we performed fecal microbiota analysis by 16S rRNA gene amplicon pyrosequencing of 14 pairs of healthy donors and RCDI patients treated successfully by FMT. Post-FMT patient and healthy donor samples collected up to one year after FMT were studied longitudinally, including one post-FMT patient with antibiotic-associated relapse three months after FMT. This analysis allowed us not only to confirm prior reports that RCDI is associated with reduced diversity and compositional changes in the fecal microbiota, but also to characterize previously undocumented post-FMT microbiota dynamics. Members of the Streptococcaceae, Enterococcaceae, or Enterobacteriaceae were significantly increased and putative butyrate producers, such as Lachnospiraceae and Ruminococcaceae were significantly reduced in samples from RCDI patients before FMT as compared to post-FMT patient and healthy donor samples. RCDI patient samples showed more case-specific variations than post-FMT patient and healthy donor samples. However, none of the bacterial groups were invariably associated with RCDI or successful treatment by FMT. Overall microbiota compositions in post-FMT patients, specifically abundances of the above-mentioned Firmicutes, continued to change for at least 16 weeks after FMT, suggesting that full microbiota recovery from RCDI may take much longer than expected based on the disappearance of diarrheal symptoms immediately after FMT.

Epidemiology of Clostridium difficile infection

There has been dramatic change in the epidemiology of Clostridium difficile infection (CDI) since the turn of the 21st century noted by a marked increase in incidence and severity, occurring at a disproportionately higher frequency in older patients. Historically considered a nosocomial infection associated with antibiotic exposure, CDI has now also emerged in the community in populations previously considered low risk. Emerging risk factors and disease recurrence represent continued challenges in the management of CDI. The increased incidence and severity associated with CDI has coincided with the emergence and rapid spread of a previously rare strain, ribotype 027. Recent data from the United States and Europe suggest that the incidence of CDI may have reached a crescendo in the recent years and is perhaps beginning to plateau. The acute care direct costs of CDI were estimated to be US$4.8 billion in 2008. However, nearly all the published studies have focused on CDI diagnosed and treated in the acute care hospital setting and fail to measure the burden outside the hospital, including recently discharged patients, outpatients, and those in long-term care facilities. Enhanced surveillance methods are needed to monitor the incidence, to identify populations at risk, and to characterize the molecular epidemiology of strains causing CDI.

Polymerase chain reaction test for Clostridium difficile toxin B gene reveals similar prevalence rates in children with and without inflammatory bowel disease

OBJECTIVE

Clinicians often evaluate for Clostridium difficile infection (CDI) in patients with inflammatory bowel disease (IBD) presenting with exacerbations. A highly sensitive polymerase chain reaction (PCR) test for the toxin B gene of C difficile is increasingly used to diagnose CDI. The aim of this study was to determine the prevalence of positive C difficile PCR results in children and young adults with and without active IBD compared with patients with non-IBD gastrointestinal disease.

METHODS

Fecal samples were obtained from patients with ulcerative colitis (UC, n = 76) or Crohn disease (CD, n = 69) and 51 controls followed in our gastroenterology program. Samples were analyzed for C difficile using a PCR test for the C difficile toxin B gene (BD GeneOhm Cdiff assay). Proportions of positive tests in each group were compared using the Pearson χ2 test.

RESULTS

The prevalence of positive PCR results was 11.6% in patients with CD, 18.4% in patients with UC, and 11.8% in controls (P = 0.25). There were no significant differences in the prevalence of positive C difficile results among patients with IBD with and without active disease or among patients with and without diarrhea.

CONCLUSIONS

Positive C difficile PCR results occur with similar frequency in patients with IBD with and without active disease and in patients with other gastrointestinal diseases. A positive result in a highly sensitive PCR assay that detects low copy numbers of a toxin gene in C difficile may reflect colonization in a subset of patients with IBD, confounding clinical decision making in managing disease exacerbations.

Inflammatory bowel disease: role of diet, microbiota, life style

Inflammatory bowel disease (IBD) encompassed several chronic inflammatory disorders leading to damage of the gastrointestinal tract (GI). The 2 principal forms of these disorders are ulcerative colitis (UC) and Crohn disease (CD). Bacteria are involved in the etiology of IBD, and the genetic susceptibility, environmental factors, and lifestyle factors can affect the individual's predisposition to IBD. The review discusses the potential role of environmental factors such as diet and microbiota as well as genetics in the etiology of IBD. It is suggested that microbial ecosystem in the human bowel colonizing the gut in many different microhabitats can be influence by diet, leading to formation of metabolic processes that are essential form the bowel metabolism.

Clostridium difficile: epidemiology, pathogenesis, management, and prevention of a recalcitrant healthcare-associated pathogen

Clostridium difficile is the leading cause of healthcare-associated infectious diarrhea. Although C difficile is part of normal flora in some healthy individuals, patients with selective risk factors are often vulnerable to the toxigenic potential of this virulent healthcare pathogen. The spectrum of C difficile infection (CDI) is highly variable, ranging from mild to severe illness, presenting with single to multiple disease recurrences. Current approaches to treatment are based on severity of illness, number of recurrences, and clinical presentation. Oral vancomycin and metronidazole have formed the foundation for treatment of CDI, but therapeutic failures are commonly reported, especially involving hypervirulent clones. Alternative therapies, including newer antimicrobials, probiotics, immunotherapy, and fecal transplantation, have all met with varying degrees of efficacy. Although toxigenic culture (TC) testing from anaerobic culture remains the gold standard, newer technologies, including enzyme immunoassay, common antigen (glutamate dehydrogenase) testing, and real-time polymerase chain reaction (PCR) are less time-consuming and rapid. However, TC and PCR have reported high specificity and sensitivity when compared with other laboratory tests. Because of the significant morbidity and mortality associated with CDI, a high index of suspicion is warranted. Prevention and eradication of CDI require a multidisciplinary approach, including early disease recognition through appropriate surveillance, implementation of effective contact isolation strategies, adherence to environmental controls, judicious hand hygiene, evidence-based treatment, and management that includes antibiotic stewardship, continuous education of healthcare workers, and administrative support.

Clostridium difficile infection is associated with worse long term outcome in patients with ulcerative colitis

BACKGROUND

Clostridium difficile infection (CDI) is becoming prevalent in general population as well as in patients with inflammatory bowel disease (IBD).

AIM

The aim of the study was to investigate the long-term impact of CDI in patients with ulcerative colitis (UC).

METHODS

UC inpatients or outpatients who had positive results for stool C. difficile toxins A and B between 2002 and 2007 were identified (N=45). The 45 patients were matched for age and gender to UC patients who were negative for C. difficile and had never been diagnosed with CDI (N=101). The primary Colectomy within 12 months of C. difficile testing was the primary outcome patients with CDI and no-CDI.

RESULTS

Forty-five patients were CDI positive and 101 were negative. Patients who were CDI positive had significantly more UC-related emergency room visits in the year following initial infection (37.8% vs. 4%, p<0.001) than those without CDI. One year following the index infection admission, CDI patients also had a significantly higher rate of colectomy than controls (35.6% vs. 9.9%, p<0.001). Among patients with CDI, 55.8% of patients had an escalation in medical treatment in the year after CDI as compared to the prior year of 12.9%, p<0.0001. CDI (odds ratio (OR) 10.0, 95% confidence interval CI: 2.7, 36.3, p<0.001) and severe disease on endoscopy (OR 16.7, 95% (CI): 4.1, 67.9, p<0.001) were found to be independently associated with colectomy within 1 year on logistic regression analyses.

CONCLUSIONS

CDI appears to be associated with escalation of medical therapy in the year following infection. CDI and severe disease on endoscopy appear to be associated with an increased risk for subsequent colectomy on long-term follow up.

Impact of Clostridium difficile infection in patients with ulcerative colitis

BACKGROUND

Clostridium difficile infection (CDI) is becoming prevalent in general population as well as in patients with inflammatory bowel disease (IBD).

AIM

The aim of the study was to identify risk factors for CDI in patients with ulcerative colitis (UC) and to assess outcome of UC in patients following CDI.

METHODS

UC inpatients or outpatients who had positive results for C. difficile toxins A and B between 2000 and 2006 were identified (N=39) and matched for age and gender to UC patients who were negative C. difficile toxins and had never been diagnosed with CDI (N=39). Records were reviewed for adverse clinical outcome, defined as colectomy within 3 months of C. difficile testing. Conditional logistic regression was used to analyze multivariable association to identify risk factors for CDI and for adverse clinical outcome.

RESULTS

A total of 78 subjects were analyzed, 60% were males. Median age was 39. Among 39 patients with CDI, 20 (47.2%) were diagnosed as outpatients, 50% failed treatment with the first antibiotic monotherapy, and 21.2% had recurrent infection. Antibiotic exposure within 30 days prior to C. difficile testing was found to be associated with an increased risk for CDI with an odds ratio of 12.0 (95% CI 1.2, 124.2) Subsequent colectomy within 3 months after CDI diagnosis, was not associated with CDI in both univariable and multivariable analyses. After adjusting for CDI, lack of 5-aminosalicylic acid (ASA) in the treatment regimen was significantly associated with colectomy with an odds ratio of 3.3 (95% CI: 1.2, 9.4). There was no UC- or CDI-associated mortality in this case series.

CONCLUSIONS

Recent antibiotic exposure was a risk factor for CDI in UC patients. Interestingly, CDI does not seem to adversely affect short-term adverse clinical outcome (colectomy).

Clostridium difficile infection in patients with inflammatory bowel disease

Clostridium difficile infection in patients with inflammatory bowel disease has become a serious clinical problem over the past few years. This review is focused on the current changes in epidemiology, pertinent clinical aspects, standard and newer diagnostic methods, established and novel therapies, and prevention of infection. There is emphasis on the importance of clinical awareness, rapid detection by stool testing, and appropriate antibiotic therapy, while newer technologies, antibiotics and other treatments are explored.