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

Risk Factors for Clostridoides Difficile Infection

Risk factors for CDI in the general population include hospitalization, antibiotic exposure, age more than 65 years, female sex, immune suppression, and multiple medical comorbidities.[2,5] However, patients with IBD appear be at greater risk for CDI. This population has increased interactions with healthcare settings, exposure to immunosuppressive medications, and altered gut microbiomes which may predispose individuals to CDI. In a prospective analysis of IBD patients in clinical remission with no recent hospitalizations or exposures to corticosteroids, immunomodulators, or antibiotics, asymptomatic carriage of toxigenic C. difficile was higher among IBD patients compared with healthy controls (8.2 vs. 1.0%).[6] Although no patients experienced symptoms of CDI during the 6-month follow-up period, the higher rate of colonization among IBD patients could be due to alterations in gut commensal bacteria and the mucosal immune response. Estimates of CDI from the Nationwide Inpatient Sample between 1998 and 2004 suggest that the prevalence of CDI among ulcerative colitis and Crohn's disease patients were 37.3 per 1000 and 10.9 per 1000, respectively, compared with 4.5 per 1000 non-IBD patients.[7]

Within the IBD population, risk factors for CDI have been reported variably in the literature. Emergency room visits, hospitalizations, and recent NSAID use appear to be associated with a higher risk of CDI among IBD patients.[8,9] Data regarding the association between CDI and use of proton-pump inhibitors and antibiotics are conflicting.[10–18] Similarly, some studies have implicated immunomodulator use as an independent risk factor for CDI while others have argued no association or even a protective effect against CDI.[5,9,12,14,19–21] In a recent meta-analysis of 22 studies, colonic involvement of IBD, biologic use, and antibiotic use were found to be independent risk factors associated with CDI among patients with IBD.[22]

There also appears to be an increased risk of complications for IBD patients with concomitant CDI. These individuals have a higher rate of IBD exacerbation requiring escalation of therapy, emergency department visits, longer hospital stays, and higher rates of surgery.[20,23–26] In a nationwide analysis, the rate of colectomy among hospitalized ulcerative colitis patients increased from 4.3 to 8.8%.[27] In addition, two recent meta-analyses suggest a higher risk of colectomy among IBD patients with CDI and two suggest a higher risk of mortality.[22,28–30] Therefore, the prompt recognition and appropriate management of both CDI and IBD in this vulnerable population is critical to minimize adverse outcomes.