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Gisbert JP, Chaparro M. Common Mistakes in Managing Patients with Inflammatory Bowel Disease. J Clin Med 2024; 13:4795. [PMID: 39200937 PMCID: PMC11355176 DOI: 10.3390/jcm13164795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 08/12/2024] [Accepted: 08/13/2024] [Indexed: 09/02/2024] Open
Abstract
Introduction: Errors are very common in medical practice and in particular, in the healthcare of patients with inflammatory bowel disease (IBD); however, most of these can be prevented. Aim: To address common errors in the management of IBD. Methods: Our approach to this problem consists in identifying mistakes frequently observed in clinical practice (according to our experience) in the management of patients with IBD, then reviewing the scientific evidence available on the subject, and finally proposing the most appropriate recommendation for each case. Results: The most common mistakes in the management of IBD include those related to diagnosis and differential diagnosis, prevention, nutrition and diet, treatment with different drugs (mainly 5-aminosalicylates, corticosteroids, thiopurines, and anti-TNF agents), extraintestinal manifestations, anemia, elderly patients, pregnancy, and surgery. Conclusions: Despite the availability of guidelines for both disease management and preventive aspects of IBD care, a considerable variation in clinical practice still remains. In this review, we have identified common mistakes in the management of patients with IBD in clinical practice. There is a clear need for a greater dissemination of clinical practice guidelines among gastroenterologists and for the implementation of ongoing training activities supported by scientific societies. Finally, it is desirable to follow IBD patients in specialized units, which would undoubtedly be associated with higher-quality healthcare and a lower likelihood of errors in managing these patients.
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Affiliation(s)
- Javier P. Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IIS-Princesa), Universidad Autónoma de Madrid (UAM), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), 28006 Madrid, Spain;
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Cook L, Wong MQ, Rees WD, Schick A, Lisko DJ, Lunken GR, Wang X, Peters H, Oliveira L, Lau T, Mah R, Bressler B, Levings MK, Steiner TS. Dysregulated Immunity to Clostridioides difficile in IBD Patients Without a History of Recognized Infection. Inflamm Bowel Dis 2024; 30:820-828. [PMID: 37874904 PMCID: PMC11063544 DOI: 10.1093/ibd/izad238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND & AIMS Clostridioides difficile is a toxin-secreting bacteria that is an urgent antimicrobial resistance threat, with approximately 25% of patients developing recurrent infections. Inflammatory bowel disease (IBD) patients are at increased risk of severe, recurrent C. difficile infection. METHODS To investigate a role for C. difficile infection in IBD pathogenesis, we collected peripheral blood and stool from 20 each of ulcerative colitis patients, Crohn's disease patients, and healthy control subjects. We used a flow cytometric activation induced marker assay to quantify C. difficile toxin-specific CD4+ T cells and 16S ribosomal RNA sequencing to study microbiome diversity. RESULTS We found IBD patients had significantly increased levels of C. difficile toxin B-specific CD4+ T cells, but not immunoglobulin G or immunoglobulin A, compared with healthy control subjects. Within antigen-specific CD4+ T cells, T helper type 17 cells and cells expressing the gut homing receptor integrin β7 were reduced compared with healthy control subjects, similar to our previous study of non-IBD patients with recurrent C. difficile infection. Stool microbiome analysis revealed that gut homing, toxin-specific CD4+ T cells negatively associated with microbial diversity and, along with T helper type 17 cells, positively associated with bacteria enriched in healthy control subjects. CONCLUSIONS These data suggest that IBD patients, potentially due to underlying intestinal dysbiosis, experience undiagnosed C. difficile infections that result in impaired toxin-specific immunity. This may contribute to the development of inflammatory T cell responses toward commensal bacteria and provide a rationale for C. difficile testing in IBD patients.
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Affiliation(s)
- Laura Cook
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- BC Children’s Hospital Research Institute, Vancouver, BC, Canada
- Department of Microbiology and Immunology, University of Melbourne at The Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - May Q Wong
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- BC Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - William D Rees
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- BC Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - Alana Schick
- Gut4Health, BC Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - Daniel J Lisko
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- BC Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - Genelle R Lunken
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Xiaojiao Wang
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- BC Children’s Hospital Research Institute, Vancouver, BC, Canada
| | - Hannah Peters
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Laura Oliveira
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Torey Lau
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Regan Mah
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Brian Bressler
- Gastrointestinal Research Institute, Vancouver, BC, Canada
| | - Megan K Levings
- BC Children’s Hospital Research Institute, Vancouver, BC, Canada
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
- School of Biomedical Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Theodore S Steiner
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- BC Children’s Hospital Research Institute, Vancouver, BC, Canada
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Jun YK, Koh SJ, Myung DS, Park SH, Ooi CJ, Sood A, Im JP. Infectious complications in patients with inflammatory bowel disease in Asia: the results of a multinational web-based survey in the 8th Asian Organization for Crohn's and Colitis meeting. Intest Res 2023; 21:353-362. [PMID: 37533266 PMCID: PMC10397552 DOI: 10.5217/ir.2023.00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/24/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND/AIMS Infectious complications are major concerns when treating patients with inflammatory bowel disease (IBD). This study evaluated clinical differences across countries/regions in the management of infectious diseases in patients with IBD. METHODS A multinational online questionnaire survey was administered to participants at the 8th meeting of the Asian Organization for Crohn's and Colitis. The questionnaire included questions regarding surveillance, diagnosis, management, and prevention of infection in patients with IBD. RESULTS A total of 384 physicians responded to the questionnaire. The majority of Korean (n=70, 63.6%) and Chinese (n=51, 51.5%) physicians preferred vancomycin to metronidazole in the treatment of Clostridium difficile infection, whereas more than half of the Japanese physicians (n=62, 66.7%) preferred metronidazole. Physicians in Korea (n=88, 80.0%) and China (n=46, 46.5%) preferred a 3-month course of isoniazid and rifampin to treat latent tuberculosis infection, whereas most physicians in Japan (n=71, 76.3%) favored a 9-month course of isoniazid. Most Korean physicians (n=89, 80.9%) recommended hepatitis B virus (HBV) vaccination in patients lacking HBV surface antigen, whereas more than half of Japanese physicians (n=53, 57.0%) did not consider vaccination. CONCLUSIONS Differences in the diagnosis, prevention, and management of infections in patients with IBD across countries/regions reflect different prevalence rates of infectious diseases. This survey may broaden understanding of the real-world clinical settings across Asian countries/regions and provide information for establishing practical guidelines to manage patients with IBD.
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Affiliation(s)
- Yu Kyung Jun
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Seong-Joon Koh
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Dae Seong Myung
- Department of Gastroenterology, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Choon Jin Ooi
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
| | - Ajit Sood
- Department of Gastroenterology, Dayanand Medical College and Hospital, Ludhiana, India
| | - Jong Pil Im
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
- Division of Gastroenterology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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Application of Procalcitonin for the Rapid Diagnosis of Clostridioides difficile Infection in Patients with Inflammatory Bowel Disease. Diagnostics (Basel) 2022; 12:diagnostics12123108. [PMID: 36553115 PMCID: PMC9776920 DOI: 10.3390/diagnostics12123108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/27/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022] Open
Abstract
Background: The incidence of Clostridioides difficile infection (CDI) has increased in recent years in patients with inflammatory bowel disease (IBD). C. difficile is a toxin-producing bacterium, and CDI results in the worsening of underlying IBD, increasing the risk of IBD treatment failure, surgery, and hospitalization. Because the symptoms of CDI overlap with those of IBD, it is challenging to make a differential diagnosis. Therefore, early, rapid, and reliable diagnostic tools that can identify CDI in IBD patients would be valuable to clinicians. Methods: This study retrospectively collected 135 patients with IBD. Among them, 44 patients were diagnosed with CDI, and 42 patients were diagnosed with viral or fungal infections. A total of 49 patients without infections were defined as the control group. The diagnostic values of procalcitonin (PCT), C-reactive protein (CRP), and white blood cell (WBC) count in the peripheral blood were examined. Results: In this study, PCT levels were significantly higher in patients with CDI than in non-CDI patients (including patients with viral/fungal infections and the control group; p < 0.001 and p < 0.05, respectively). CRP levels were significantly higher in patients with CDI than in non-CDI patients (p < 0.05). The area under the curve (AUC) of PCT and WBC count were compared using DeLong’s test: the AUCs of PCT vs. CRP for the detection of the IBD−CDI group and the control group was 0.826 [95% confidence interval (CI) 0.743−0.909] vs. 0.663 [95% confidence interval (CI) 0.551−0.774] (p < 0.05), respectively. WBC count was inferior as a diagnostic tool for CDI. The sensitivity was 59.09% (95% CI: 43.2% to 73.7%), the specificity was 89.80% (95% CI: 77.8% to 96.6%), and the positive likelihood ratio LR (+) was 5.79 for PCT for the diagnosis of CDI. Conclusions: The present study demonstrates the superiority of PCT over CRP and WBC count for the rapid diagnosis of CDI in IBD patients.
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Li Y, Cai H, Sussman DA, Donet J, Dholaria K, Yang J, Panara A, Croteau R, Barkin JS. Association Between Immunosuppressive Therapy and Outcome of Clostridioides difficile Infection: Systematic Review and Meta-Analysis. Dig Dis Sci 2022; 67:3890-3903. [PMID: 34554365 DOI: 10.1007/s10620-021-07229-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 08/11/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with Clostridioides difficile infection (CDI) often have coexisting medical problems requiring immunosuppressive therapy. However, limited data are available on the association between immunosuppressive therapy and CDI outcomes. AIM To determine the association between immunosuppressive therapy and CDI outcomes. METHODS PubMed, Embase, and Cochrane Library were searched through February 2021. Two reviewers independently reviewed and included studies that compared adult CDI patients who received immunosuppressive therapy to those who did not. The primary outcome was complicated CDl, including death, surgery, shock, or ICU admission. Raw data or unadjusted odds ratios (ORs) were used to calculate pooled ORs with 95% confidence intervals (CIs). RESULTS Twenty-two studies with a total of 5759 CDI patients were selected. Immunosuppressive therapy was significantly associated with both primary outcome and death, with pooled ORs of 1.61 (95% CI 1.33-1.96) and 1.73 (95% CI 1.39-2.15) separately. The association between corticosteroids and primary outcome was also significant with OR of 1.73 (95% CI 1.41, 2.12). In subgroup analysis, the factors explaining differences in study results included study quality, patient age, and whether individual studies had adjusted for potential confounders. In a systematic review, most studies suggested a positive association between immunosuppressive therapy and complicated outcomes of CDI in patients comorbid for IBD. CONCLUSIONS Our systematic review and meta-analysis demonstrate that immunosuppressive therapy is a risk factor for complicated outcomes of CDI.
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Affiliation(s)
- Yiting Li
- Department of Internal Medicine, Saint Francis Medical Center, Trenton, NJ, USA
- Division of Gastroenterology and Hepatology, University of New Mexico, School of Medicine, Albuquerque, NM, USA
| | - Haifeng Cai
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Childrens Hospital of Wenzhou Medical University, 109 Xue Yuan Xi Road, Wenzhou, 325000, Zhejiang, China
| | - Daniel A Sussman
- Division of Gastroenterology, Department of Medicine, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Jean Donet
- Department of Gastroenterology and Hepatology, University of California, San Francisco, Fresno, CA, USA
| | | | - Jiajia Yang
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Ami Panara
- Division of Gastroenterology, Department of Medicine, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Ryan Croteau
- Department of Gastroenterology, Wellspan Digestive Health, York, PA, USA
| | - Jamie S Barkin
- Division of Gastroenterology, Department of Medicine, University of Miami, Miller School of Medicine, Miami, FL, USA.
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Di Re A, Liang Y, Gosselink MP, Ctercteko G. Acute Gastroenteritis in the Etiology of Inflammatory Bowel Disease: Systematic Review and Meta-analysis. CROHN'S & COLITIS 360 2021; 3:otab065. [PMID: 36777279 PMCID: PMC9802281 DOI: 10.1093/crocol/otab065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Indexed: 02/07/2023] Open
Abstract
Background Inflammatory bowel disease (IBD) consists of a spectrum of disorders including ulcerative colitis and Crohn's disease, with a rising incidence worldwide. However, despite this prevalence the etiology of IBD remains uncertain. It has been suggested that an episode of gastroenteritis may precipitate IBD. Methods Studies were identified using a literature search of Pubmed/Medline and Embase/Ovid. This review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The primary outcome was incidence of new-onset IBD after gastroenteritis. Secondary outcomes included incidence of IBD after bacterial, viral, and parasitic gastrointestinal infections. Results Eleven studies (n = 923 608 patients) were included. Four studies assessed patients with gastroenteritis, subsequently developing IBD as the primary outcome. Patients with gastroenteritis had a higher incidence of subsequent IBD but this did not reach statistical significance (odds ratio [OR] 3.81, 95% CI 0.52-27.85, P = .19). Seven studies examined the incidence of antecedent gastroenteritis (primary outcome) in patients with a confirmed diagnosis of IBD, compared to the controlled population. There was no difference between incidence of antecedent gastroenteritis across the 2 population groups (OR 1.07, 95% CI 0.55-2.08, P = .85). There was no association between IBD and bacterial, viral, or parasitic infections. Conclusions In summary, our meta-analysis has shown that there is considerable heterogeneity in the literature regarding the role of gastroenteritis in the development of IBD. Further higher quality studies need to be performed to ascertain the true nature of this.
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Affiliation(s)
- Angelina Di Re
- Department of Colorectal Surgery, Westmead Hospital, Westmead, New South Wales, Australia,School of Medicine, University of Sydney, Camperdown, New South Wales, Australia,Address correspondence to: Angelina Di Re, MBBS, MS, Department of Colorectal Surgery, Westmead Hospital, Cnr Hawkesbury Rd and Darcy Rd, Westmead, NSW 2145, Australia ()
| | - Yi Liang
- Department of Colorectal Surgery, Westmead Hospital, Westmead, New South Wales, Australia,Department of General Surgery, Blacktown Hospital, Blacktown, New South Wales, Australia
| | - Martijn Pieter Gosselink
- Department of Colorectal Surgery, Westmead Hospital, Westmead, New South Wales, Australia,Department of Colorectal Surgery, Dr. Horacio E Oduber Hospital, Caya Punta Brabo, Aruba
| | - Grahame Ctercteko
- Department of Colorectal Surgery, Westmead Hospital, Westmead, New South Wales, Australia,School of Medicine, University of Sydney, Camperdown, New South Wales, Australia
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Gupta A, Wash C, Wu Y, Sorrentino D, Nguyen VQ. Diagnostic Modality of Clostridioides difficile Infection Predicts Treatment Response and Outcomes in Inflammatory Bowel Disease. Dig Dis Sci 2021; 66:547-553. [PMID: 32207033 DOI: 10.1007/s10620-020-06205-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 03/10/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) patients are at increased risk of developing Clostridioides difficile infection (CDI). Common methods to diagnose CDI involve a combination of tests including the toxin A/B enzyme immunoassay (Toxin) and toxin gene polymerase chain reaction assay (PCR). Disease outcomes in Toxin+ versus Toxin-PCR+ IBD patients remain unclear. AIMS This study aimed to examine the response to antibiotics and risk of IBD therapy escalation in Toxin+ versus Toxin-PCR+ patients. METHODS IBD patients at an academic center with CDI diagnosis based on Toxin+ or Toxin-PCR+ from 2012 to 2017 were identified. Comparisons of response to antibiotics within 30 days and escalation of IBD therapy within 90 days of CDI diagnosis between these two groups were analyzed by Chi-square analysis. Multivariable regression analysis examined factors associated with antibiotic response. RESULTS Among 92 patients included, 61% had Crohn's disease and 39% had ulcerative colitis. 70% tested Toxin-PCR+. 60% received vancomycin or fidaxomicin to treat CDI. 82% of Toxin+ patients responded to antibiotics compared to 25% of Toxin-PCR+ patients (p < 0.001). 21% of Toxin+ patients required IBD therapy escalation compared to 63% of Toxin-PCR+ patients (p < 0.001). When adjusted for the types of antibiotics used, IBD subtypes, and immunosuppression status, positivity to Toxin (OR 14.85, CI 4.62-47.72) was the most significant predictor of response to antibiotics. CONCLUSIONS Toxin+ compared to Toxin-PCR+ IBD patients had a significantly higher rate of response to antibiotics and lower chances of requiring IBD therapy escalation. Future outcome studies involving CDI in IBD patients should be stratified by modality of diagnosis.
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Affiliation(s)
- Annu Gupta
- IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of Medicine, 3 Riverside Circle, Roanoke, VA, 24016, USA
| | - Christopher Wash
- IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of Medicine, 3 Riverside Circle, Roanoke, VA, 24016, USA
| | - Yingxing Wu
- IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of Medicine, 3 Riverside Circle, Roanoke, VA, 24016, USA
| | - Dario Sorrentino
- IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of Medicine, 3 Riverside Circle, Roanoke, VA, 24016, USA
- Department of Clinical and Experimental Medical Sciences, University of Udine School of Medicine, Udine, Italy
| | - Vu Q Nguyen
- IBD Center, Division of Gastroenterology, Virginia Tech Carilion School of Medicine, 3 Riverside Circle, Roanoke, VA, 24016, USA.
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Low glutamate dehydrogenase levels are associated with colonization in Clostridium difficile PCR-only positive patients with inflammatory bowel disease. Eur J Gastroenterol Hepatol 2020; 32:1099-1105. [PMID: 32516177 DOI: 10.1097/meg.0000000000001762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND/AIMS Clostridioides difficile infection (CDI) remains a diagnostic challenge in patients with inflammatory bowel disease (IBD). We tested novel biomarkers to differentiate CDI from colonization in patients without (CDI-only) and with IBD (IBD-CDI). METHODS Samples were enzyme immunoassay (EIA)-tested for glutamate dehydrogenase (GDH) and toxin, followed by reflex PCR. Quantitative GDH [(qGDH) - a novel indicator of Clostridium difficile load] and stool lactoferrin were tested at days 0, 3 and 10 during antibiotic treatment. Samples were also analyzed for toxin B cytotoxicity neutralization assay (CNA) and toxigenic culture, gold standards to detect free toxin and virulent bacteria, respectively. RESULTS Forty-five symptomatic patients (28 CDI-only, 13 with Crohn's disease, 4 with ulcerative colitis) were recruited with 3 sequential samples available for 36 (21 CDI-only, 15 IBD-CDI). Thirty-nine of 45 (87%) cases were toxigenic culture-positive. In the CDI-only group, 78.6% were positive for EIA-toxin, 21.4% were PCR-positive while 82.1% were CNA-positive. In the IBD-CDI group, only one patient (6%) was EIA-toxin positive and 17.6% CNA-positive. The median qGDH level at day 0 was higher in CNA-positive patients compared to CNA-negative patients (1111 vs. 146 ng/g, P = 0.004) and dropped together with lactoferrin from day 0 to 10. CDI eradication improved symptoms in 72.2% of patients with CDI-only. In 60% of patients with IBD-CDI, eradication was ineffective, with symptoms improving in 89% of them after IBD therapy intensification. CONCLUSION In patients with IBD-CDI, PCR-only positivity might mainly reflect colonization rather than disease. C. difficile load by qGDH correlates with CNA-detected toxin and together with stool lactoferrin might differentiate CDI from colonization in patients with IBD.
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Wu Q, Savidge TC. Systems approaches for the clinical diagnosis of Clostridioides difficile infection. Transl Res 2020; 220:57-67. [PMID: 32272094 DOI: 10.1016/j.trsl.2020.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/02/2020] [Accepted: 03/09/2020] [Indexed: 12/18/2022]
Abstract
Clostridioides difficile infection (CDI) is an urgent threat to global public health. Patient susceptibility to C. difficile is highly dependent on host immune status and gut dysbiosis resulting in loss of protective microbiota consortia that prevent spore germination, pathogen colonization, and disease pathogenesis. Recent clinical studies highlight the problems of differentiating symptomatic CDI from asymptomatic C. difficile carriage in patients with diarrhea. In this review, we consider how integration of microbiome and host immune systems biology data may aid in the clinical diagnosis of CDI when validated against gold standard testing and combined with standard microbiology laboratory assays.
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Affiliation(s)
- Qinglong Wu
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, Houston, Texas
| | - Tor C Savidge
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; Texas Children's Microbiome Center, Department of Pathology, Texas Children's Hospital, Houston, Texas.
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Moens A, Verstockt B, Machiels K, Bossuyt P, Verdonck A, Lagrou K, van Assche G, Vermeire S, Ferrante M. Clostridium difficile infection in inflammatory bowel disease: epidemiology over two decades. Eur J Gastroenterol Hepatol 2019; 31:668-673. [PMID: 30839436 DOI: 10.1097/meg.0000000000001394] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND The incidence of Clostridium difficile infection (CDI) has been rising in the overall population as well as in patients with inflammatory bowel disease (IBD). However, the incidence of CDI in IBD may be changing owing to alterations in medical therapies. OBJECTIVE The aim of this study was to establish the incidence of CDI in IBD over the past two decades and compare risk factors, disease characteristics and outcomes between IBD and non-IBD patients. PATIENTS AND METHODS In this retrospective case-control study, the incidence of CDI in IBD was followed for 18 years. The electronic database of our centre was reviewed for all stool samples received from patients admitted to gastroenterology wards or visiting the outpatient clinic. Diagnosis of CDI was based on diagnostic criteria that evolved throughout the years. RESULTS IBD patients (n=44) with CDI were found to be younger (P=0.0001), have less cardiovascular comorbidity (P=0.023), fewer prior hospitalizations (P=0.009) and fewer prior antibiotic use (P=0.005). More IBD patients were on biologic therapy (P=0.0001) or steroids (P=0.001) but less likely taking proton pump inhibitors (P=0.001). The number of stool testing per year increased as well as the median number of positive stool samples for CDI (2% in 2000-2008 to 3% in 2009-2017, P=0.032). Pseudomembranes were only seen in non-IBD patients (28%, P=0.048). There was no difference in the choice of antibiotics between IBD and non-IBD patients [metronidazole (36 vs. 51%) and vancomycin (36 vs. 26%), P=0.090 and 0.190]. The 1-year mortality rate was lower in IBD patients compared with non-IBD patients (0 vs. 32%, P=0.0001). CONCLUSION In the past two decades, the incidence of CDI in IBD and non-IBD patients has increased. However, the overall outcome of CDI in IBD patients was favourable compared with non-IBD patients.
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Affiliation(s)
- Annick Moens
- Departments of Gastroenterology and Hepatology
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven
| | - Bram Verstockt
- Departments of Gastroenterology and Hepatology
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven
| | - Kathleen Machiels
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven
| | - Peter Bossuyt
- Department of Gastroenterology and Hepatology, Imelda Hospital, Bonheiden, Belgium
| | - Ann Verdonck
- Laboratory Medicine, University Hospitals Leuven
| | | | - Gert van Assche
- Departments of Gastroenterology and Hepatology
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven
| | - Séverine Vermeire
- Departments of Gastroenterology and Hepatology
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven
| | - Marc Ferrante
- Departments of Gastroenterology and Hepatology
- Department of Chronic Diseases, Metabolism and Ageing, KU Leuven, Leuven
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Alonso CD, Mahoney MV. Bezlotoxumab for the prevention of Clostridium difficile infection: a review of current evidence and safety profile. Infect Drug Resist 2018; 12:1-9. [PMID: 30588042 PMCID: PMC6301304 DOI: 10.2147/idr.s159957] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Clostridium difficile infection (CDI) is a leading nosocomial disease estimated to cause nearly half a million cases in the United States annually. Recurrent CDI (rCDI) affects ~25% of patients after completion of standard of care therapy and is associated with substantial health care costs and a negative impact on patient's overall markers of quality of life. Bezlotoxumab is the first of its kind monoclonal antibody directed against C. difficile toxin B and indicated for prevention of rCDI in at-risk patients. For the present review, we assessed English-language studies evaluating the clinical efficacy, safety, and pharmacokinetics of bezlotoxumab in humans. Relevant studies were obtained through PubMed, Embase, Cochrane database library, Web of Science, and clinicaltrials.gov. Overall, bezlotoxumab demonstrated a 40% relative reduction rate (absolute rate reduction of ~10%) and a number needed to treat of 10 patients with a favorable safety profile. Special populations, including the elderly, immunocompromised, and patients with end-stage renal disease were evaluated in post hoc analyses with a similarly favorable reduction in rCDI. This review presents and interprets the most recent safety data and the clinical application of bezlotoxumab, highlighting specific high-risk patient populations.
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Affiliation(s)
- Carolyn D Alonso
- Department of Medicine, Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA, USA,
- Harvard Medical School, Boston, MA, USA,
| | - Monica V Mahoney
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
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12
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Kelly CP, Wilcox MH, Glerup H, Aboo N, Ellison MC, Eves K, Dorr MB. Bezlotoxumab for Clostridium difficile Infection Complicating Inflammatory Bowel Disease. Gastroenterology 2018; 155:1270-1271. [PMID: 30227108 DOI: 10.1053/j.gastro.2018.06.080] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/11/2018] [Accepted: 06/18/2018] [Indexed: 12/02/2022]
Affiliation(s)
| | - Mark H Wilcox
- Leeds Teaching Hospitals and University of Leeds, Leeds, UK
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13
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Li Z, Liu X, Zhao J, Xu K, Tian T, Yang J, Qiang C, Shi D, Wei H, Sun S, Cui Q, Li R, Niu Y, Huang B. Comparison of a newly developed binary typing with ribotyping and multilocus sequence typing methods for Clostridium difficile. J Microbiol Methods 2018; 147:50-55. [DOI: 10.1016/j.mimet.2018.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/22/2018] [Accepted: 02/22/2018] [Indexed: 12/19/2022]
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14
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Abstract
Antibiotic therapy is not necessary for acute diarrhea in children, as rehydration is the key treatment and symptoms resolve generally without specific therapy. Searching for the etiology of gastroenteritis is not usually needed; however, it may be necessary if antimicrobial treatment is considered. The latter is left to the physician evaluation in the absence of clear indications. Antimicrobial treatment should be considered in severely sick children, in those who have chronic conditions or specific risk factors or in specific settings. Traveler’s diarrhea, prolonged diarrhea, and antibiotic-associated diarrhea may also require antibiotic therapy. Depending on the severity of symptoms or based on risk of spreading, empiric therapy may be started while awaiting the results of microbiological investigations. The choice of antibiotic depends on suspected agents, host conditions, and local epidemiology. In most cases, empiric therapy should be started while awaiting such results. Empiric therapy may be started with oral co-trimoxazole or metronidazole, but in severe cases parenteral treatment with ceftriaxone or ciprofloxacin might be considered.
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Affiliation(s)
- Eugenia Bruzzese
- Department of Translational Medical Sciences-Section of Pediatrics, University of Naples Federico II, Via S. Pansini 5, Naples, 80131, Italy
| | - Antonietta Giannattasio
- Department of Translational Medical Sciences-Section of Pediatrics, University of Naples Federico II, Via S. Pansini 5, Naples, 80131, Italy
| | - Alfredo Guarino
- Department of Translational Medical Sciences-Section of Pediatrics, University of Naples Federico II, Via S. Pansini 5, Naples, 80131, Italy
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15
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Maharshak N, Barzilay I, Zinger H, Hod K, Dotan I. Clostridium difficile infection in hospitalized patients with inflammatory bowel disease: Prevalence, risk factors, and prognosis. Medicine (Baltimore) 2018; 97:e9772. [PMID: 29384868 PMCID: PMC5805440 DOI: 10.1097/md.0000000000009772] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 11/06/2017] [Accepted: 01/12/2018] [Indexed: 12/20/2022] Open
Abstract
To evaluate the frequency, possible risk factors, and outcome of Clostridium difficile infection (CDI) in inflammatory bowel disease (IBD) patients.There has been an upsurge of CDI in patients with IBD who has been associated with increased morbidity and mortality. Various risk factors have been found to predispose IBD patients to CDI.A retrospective case-control study on IBD patients admitted with exacerbation and tested for CDI at the Tel Aviv Medical Center in 2008 to 2013. Epidemiologic, laboratory, and prognostic data were retrieved from electronic files and compared between patients who tested positive (CDI+) or negative (CDI-) for CDI.CDI was identified in 28 of 311 (7.31%) IBD patients hospitalized with diarrhea. IBD-specific risk factors (univariate analysis) for CDI included: use of systemic steroids therapy (odds ratio [OR] = 3.6, 95% confidence interval [CI] 1.2-10.6) and combinations of ≥2 immunomodulator medications (OR = 2.6, 95% CI 1.1-6.3). Additional risk factors for CDI that are common in the general population were hospitalization in the preceding 2 months (OR = 6.0, 95% CI 2.6-14.1), use of antacids (OR = 3.8, 95% CI 1.7-8.4), and high Charlson comorbidity score (OR = 2.5, 95% CI 1.1-5.7). A multivariate analysis confirmed that only hospitalization within the preceding 2 months and use of antacids were significant risk factors for CDI. The prognosis of CDI+ patients was similar to that of CDI- patients.Hospitalized IBD patients with exacerbation treated with antacids or recently hospitalized are at increased risk for CDI and should be tested and empirically treated until confirmation or exclusion of the infection.
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Affiliation(s)
- Nitsan Maharshak
- Department of Gastroenterology and Liver Diseases, Tel-Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University
| | - Idan Barzilay
- Department of Gastroenterology and Liver Diseases, Tel-Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University
| | - Hasya Zinger
- Department of Gastroenterology and Liver Diseases, Tel-Aviv Medical Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University
| | - Keren Hod
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University
- Research Division, Epidemiology Service, Assuta Medical Centers
| | - Iris Dotan
- Department of Gastroenterology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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16
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Zhang SL, Wang SN, Miao CY. Influence of Microbiota on Intestinal Immune System in Ulcerative Colitis and Its Intervention. Front Immunol 2017; 8:1674. [PMID: 29234327 PMCID: PMC5712343 DOI: 10.3389/fimmu.2017.01674] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 11/14/2017] [Indexed: 01/07/2023] Open
Abstract
Ulcerative colitis (UC) is an inflammatory bowel disease (IBD) with chronic and recurrent characteristics caused by multiple reasons. Although the pathogenic factors have not been clarified yet, recent studies have demonstrated that intestinal microbiota plays a major role in UC, especially in the immune system. This review focuses on the description of several major microbiota communities that affect UC and their interactions with the host. In this review, eight kinds of microbiota that are highly related to IBD, including Faecalibacterium prausnitzii, Clostridium clusters IV and XIVa, Bacteroides, Roseburia species, Eubacterium rectale, Escherichia coli, Fusobacterium, and Candida albicans are demonstrated on the changes in amount and roles in the onset and progression of IBD. In addition, potential therapeutic targets for UC involved in the regulation of microbiota, including NLRPs, vitamin D receptor as well as secreted proteins, are discussed in this review.
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Affiliation(s)
- Sai-Long Zhang
- Department of Pharmacology, Second Military Medical University, Shanghai, China
| | - Shu-Na Wang
- Department of Pharmacology, Second Military Medical University, Shanghai, China
| | - Chao-Yu Miao
- Department of Pharmacology, Second Military Medical University, Shanghai, China
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17
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Zhang H, Zhang Z, Song G, Tang X, Song H, Deng A, Wang W, Wu L, Qin H. Development of an XBP1 agonist, HLJ2, as a potential therapeutic agent for ulcerative colitis. Eur J Pharm Sci 2017; 109:56-64. [PMID: 28757346 DOI: 10.1016/j.ejps.2017.07.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/13/2017] [Accepted: 07/26/2017] [Indexed: 02/06/2023]
Abstract
There is a severe lack of effective treatments for ulcerative colitis (UC), a recurrent and intractable inflammatory bowel disease. The identification of valid targets and new drugs is an urgent need. In this study, we identified the XBP-1 agonist HLJ2 as a promising treatment candidate. In an in vivo mouse model of DSS-induced colitis, HLJ2 decreased weight loss, colon contracture, disease activity index (DAI), colon mucosa damage index (CMDI) and histopathological index (HI). HLJ2 also decreased myeloperoxidase (MPO) activity and reduced production of the inflammatory cytokines TNF-α, IL-1β, and IL-6. HLJ2 improved intestinal mucosa damage induced by dextran sodium sulfate (DSS) and increased the expression of ZO-1 and claudin-1. Fecal 16s rRNA high-throughput sequencing demonstrated a significant improvement in UC intestinal dysbacteriosis in mice treated with HLJ2, including increased abundance of probiotics such as Lachnospiraceae, Prevotellaceae, and Lactobacillaceae. At the same time there was a reduction in the abundance of pathogenic or conditional pathogenic microorganisms such as Bacteroidaceae, Porphyromonadaceae, Deferribacteraceae, and Pseudomonadaceae in HLJ2-treated mice compared with untreated mice. Our results demonstrated that the XBP1 agonist HLJ2 inhibits inflammation, regulates the intestinal flora, and protects the intestinal mucosa. It is thus a potential therapeutic agent for ulcerative colitis.
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Affiliation(s)
- HaiJing Zhang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | - ZhiHui Zhang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | | | - XiaoNan Tang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | - HuaChen Song
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | - AnJun Deng
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | - WenJie Wang
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China
| | - LianQiu Wu
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China.
| | - Hailin Qin
- State Key Laboratory of Bioactive Substances and Functions of Natural Medicines, Institute of Materia Medica, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100050, China.
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