Risk Factors for Clostridium difficile Isolation in Inflammatory Bowel Disease: A Prospective Study

Micic D1, Yarur A1, Gonsalves A1, Rao VL1, Broadaway S2, Cohen R1, Dalal S1, Gaetano JN1, Glick LR1, Hirsch A1, Pekow J1, Sakuraba A1, Walk ST2, Rubin DT3. Dig Dis Sci. 2018 Feb 8. doi: 10.1007/s10620-018-4941-7. [Epub ahead of print]

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1 University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 South Maryland Avenue, MC4076, Chicago, IL, 60637, USA.

2 Montana State University, Bozeman, MT, 59717, USA.

3 University of Chicago Medicine Inflammatory Bowel Disease Center, 5841 South Maryland Avenue, MC4076, Chicago, IL, 60637, USA. drubin@medicine.bsd.uchicago.edu.


INTRODUCTION: Clostridium difficile is the most commonly isolated stool pathogen in inflammatory boweldisease (IBD). Traditional risk factors for C. difficile may not exist in patients with IBD, and no prior studies have assessed the risk factors for the isolation of C. difficile in both symptomatic and asymptomatic IBD outpatients.

METHODS: We prospectively recruited consecutive IBD patients presenting to our outpatient clinic between April 2015 and February 2016. We excluded patients with a diverting ostomy or ileoanal pouch. Demographics, healthcare exposures, medical therapies and disease activity were recorded from medical charts or surveys. A rectal swab was performed from which toxigenic culture and PCR analysis for the presence of toxin and fluorescent PCR ribotyping were performed. The primary outcome of interest was isolation of toxigenic C. difficile.

RESULTS: A total of 190 patients were enrolled in this prospective study including 137 (72%) with Crohn's disease and 53 (28%) with ulcerative colitis. At the time of enrollment, 69 (36%) had clinically active disease. Sixteen (8.4%) patients had toxigenic C. difficile isolated on rectal swab at enrollment and four (2.1%) patients had non-toxigenic C. difficile cultured. Mixed infection with more than one toxigenic isolate was present in 5/16 (33.3%) individuals. Patients with CD with a toxin positive isolate were more likely to have a history of CDI in the past 12 months (40 vs. 11.02%, p = 0.027) and an emergency department visit in the past 12 weeks (50 vs. 20.63%, p = 0.048). In UC, individuals with isolation of C. difficile were more likely to be hospitalized within the past 12 months (66.6 vs. 8.51%, p = 0.003). C. difficile isolation at the time of presentation was not associated with a subsequent disease relapse over a 6-month period in CD (p = 0.557) or UC (p = 0.131).

CONCLUSION: Healthcare exposures remain a significant risk factor for C. difficile isolation in the IBD population; however, this was not associated with relapse of disease. Further studies assessing the clinical significance of C. difficile isolation is warranted in IBD.

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