Diagnosis and Management of Clostridioides Difficile Infection in Patients With Inflammatory Bowel Disease

Rahul S. Dalal; Jessica R. Allegretti


Curr Opin Gastroenterol. 2021;37(4):336-343. 

In This Article

Abstract and Introduction


Purpose of Review: Clostridioides difficile infection (CDI) may complicate the course of ulcerative colitis and Crohn's disease. The clinical presentation of CDI in this population is often atypical, and patients may experience exacerbations of their underlying inflammatory bowel disease (IBD) secondary to C. difficile. In this review, we aim to review the risk factors, diagnosis, and management of CDI in the context of IBD.

Recent Findings: Patients with colonic involvement of their IBD are at higher risk for CDI and colonization may be more common than in the general population. Therefore, CDI is confirmed using a two-step approach to stool testing. Oral vancomycin or fidaxomicin are the preferred agents for nonfulminant disease, and oral metronidazole is no longer recommended as first-line therapy. For all patients with CDI recurrence, fecal microbiota transplant (FMT) should be considered, as this has been shown to be safe and effective. Among those who have worsening of their underlying IBD, retrospective research suggest that outcomes are improved for those who undergo escalation of immunosuppression with appropriate antimicrobial treatment of C. difficile, however prospective data are needed.

Summary: CDI may complicate the course of IBD, however the presentation may not be typical. Therefore, all patients with worsening gastrointestinal symptoms should be evaluated for both CDI and IBD exacerbation. Providers should consider FMT for all patients with recurrent CDI as well as escalation of immunosuppression for patients who fail to improve with appropriate antimicrobial therapy.


Clostridioides difficile is an anaerobic, spore-forming bacterium and a leading cause of nosocomial diarrhea in the United States.[1] In 2011, there were an estimated 453 000 cases of initial C. difficile infection (CDI) and 29 300 CDI-associated deaths.[2] Due to efforts to reduce healthcare-associated infections, the incidence of CDI improved from 154.9 to 143.6 per 100 000 persons between 2011 and 2017.[3] However, patients with inflammatory bowel disease (IBD) have a nearly five-fold increase in risk of CDI compared with the general population.[4] In this review, we will summarize the most recent data regarding risk factors of CDI, the clinical presentations and diagnostic criteria for CDI, management of the initial episode as well as recurrent CDI, and management of IBD exacerbation in the setting of CDI.