Diagnosis and Management of C. Difficile in Patients With IBD

Conclusion

CDI is a common but serious complication of IBD that requires simultaneous attention to both conditions. All IBD patients with worsening colitis symptoms should be evaluated for CDI and providers must acknowledge that typical risk factors such as recent antibiotic exposure and pseudomembranes may not be present. Those with positive two-step stool testing should receive oral vancomycin or fidaxomicin as initial therapy and FMT should be considered for those with recurrent disease. Escalation of immunosuppression may also be needed, especially if IBD patients fail to respond to appropriate antimicrobial therapy after 3–4 days. However, treatment decisions should always be individualized.

Table 1. Studies evaluating the association between immunosuppressive medications and clinical outcomes in the setting of *Clostridioides difficile* infection among patients with inflammatory bowel disease
Reference (journal)	Design and population	Outcomes
Ben-Horin et al.[78] Clinical Gastroenterology and Hepatology	Multicenter retrospective cohort European Crohn's and Colitis Organization 155 Hospitalized IBD patients with CDI (2001–2008)	1. No independent association between immunosuppressive medications and composite outcome (death within 3 months, megacolon, bowel perforation, shock, respiratory failure): LR 11.9, 95% CI 0.9–157 2. Higher adjusted odds of composite outcome associated with 2 or more immunosuppressive medications: OR 17, 95% CI 3.1–91
Ananthakrishnan et al.[79] Alimentary Pharmacology and Therapeutics	Multiinstitutional retrospective cohort Boston, MA, USA 294 hospitalized IBD patients with CDI (1998–2010)	1. No association between immunomodulators and severe outcomes (time to colectomy or death): HR 0.57, 95% CI 0.4–1.2 2. No association between corticosteroids and severe outcomes: HR 0.9, 95% CI −0.5–1.5 3. No association between anti-TNFs and severe outcomes: HR 0.4, 95% CI 0.1–1.5
Solanky et al.[80] Inflammatory Bowel Diseases	Single-center retrospective cohort Rochester, MN, USA 137 hospitalized IBD patients with CDI (2008–2013)	1. Higher adjusted odds of colon surgery within 1 year after CDI associated with corticosteroid use: OR 5.9, 95% CI 2.0–17.4
Lukin et al.[82] Inflammatory Bowel Diseases	Multicenter retrospective cohort New York, NY, USA 207 hospitalized IBD patients with CDI (dates unknown)	1. Lower adjusted odds of severe outcomes (death, sepsis, or colectomy within 90 days) associated with IBD therapy escalation to corticosteroids or biologics: OR 0.12, 95% CI 0.02–0.9
Bar-Yoseph et al.[81] International Journal of Colorectal Disease	Single-center retrospective cohort Haifa, Israel 113 hospitalized IBD patients with CDI (2002–2018)	1. No significant difference in 1-year colectomy rates by exposure to early corticosteroids (within 48 h of admission): 8.5 vs. 0.0%, P = 0.192. 2. No significant difference in 1-year mortality rates by exposure to early corticosteroids: 6.1 vs. 16.1%, P = 0.13

Table 1. Studies evaluating the association between immunosuppressive medications and clinical outcomes in the setting of Clostridioides difficile infection among patients with inflammatory bowel disease

Reference (journal)

Design and population

Outcomes

Ben-Horin et al.[78]
Clinical Gastroenterology and Hepatology

Multicenter retrospective cohort
European Crohn's and Colitis Organization
155 Hospitalized IBD patients with CDI (2001–2008)

1. No independent association between immunosuppressive medications and composite outcome (death within 3 months, megacolon, bowel perforation, shock, respiratory failure): LR 11.9, 95% CI 0.9–157
2. Higher adjusted odds of composite outcome associated with 2 or more immunosuppressive medications: OR 17, 95% CI 3.1–91

Ananthakrishnan et al.[79]
Alimentary Pharmacology and Therapeutics

Multiinstitutional retrospective cohort
Boston, MA, USA
294 hospitalized IBD patients with CDI (1998–2010)

1. No association between immunomodulators and severe outcomes (time to colectomy or death): HR 0.57, 95% CI 0.4–1.2
2. No association between corticosteroids and severe outcomes: HR 0.9, 95% CI −0.5–1.5
3. No association between anti-TNFs and severe outcomes: HR 0.4, 95% CI 0.1–1.5

Solanky et al.[80]
Inflammatory Bowel Diseases

Single-center retrospective cohort
Rochester, MN, USA
137 hospitalized IBD patients with CDI (2008–2013)

1. Higher adjusted odds of colon surgery within 1 year after CDI associated with corticosteroid use: OR 5.9, 95% CI 2.0–17.4

Lukin et al.[82]
Inflammatory Bowel Diseases

Multicenter retrospective cohort
New York, NY, USA
207 hospitalized IBD patients with CDI (dates unknown)

1. Lower adjusted odds of severe outcomes (death, sepsis, or colectomy within 90 days) associated with IBD therapy escalation to corticosteroids or biologics: OR 0.12, 95% CI 0.02–0.9

Bar-Yoseph et al.[81]
International Journal of Colorectal Disease

Single-center retrospective cohort
Haifa, Israel
113 hospitalized IBD patients with CDI (2002–2018)

1. No significant difference in 1-year colectomy rates by exposure to early corticosteroids (within 48 h of admission): 8.5 vs. 0.0%, P = 0.192.
2. No significant difference in 1-year mortality rates by exposure to early corticosteroids: 6.1 vs. 16.1%, P = 0.13