Clostridium Difficile Infection and Infl ammatory Bowel Diseases: Frequency and Possible Risk Factors

Background and aims: The incidence of CDI among IBD patients is increasing, and has been demonstrated to be associated with increased hospitalization period, costs, morbidity and mortality, the recent guidelines advocate testing all IBD patients who are experiencing disease flare for CDI, this is a cross-sectional study to estimate the incidence and to assess possible risk factors for CDI among IBD patients who are in disease flare up. Methods: Eighty-seven patients with IBD were studied, who attended the Gastroenterology and Hepatology Teaching Hospital in the Medical City (Baghdad), during the period from January 2019 to April 2020, all with disease flare up. Patients’ demographic and clinical data including factors expected to be a risk factors or have an association with CDI such as age, sex, comorbid conditions, recent hospitalization(within 1 month), drugs including PPI, recent antibiotic exposure(within 1 month) and IBD drugs(Aminosalicylate, steroids, immunomodulators and biological therapy), in addition to the duration, severity and endoscopic extend of IBD, all have been recorded. Diagnosis of CDI was done by the detection of clostridium difficile toxin A and B in a fecal specimen using an enzyme immunoassay (ELISA). Results: A total of 87 IBD patients were enrolled in this study (62 cases of UC and 25 cases with a diagnosis of CD), female comprised 66% of cases with female to male ratio of 2:1, with a mean age of 33 years, The most frequent IBD disease duration was (2-5) years in 37 patients (42.5%) of cases, followed by > 5 years in 31 (35.6%), The highest proportion of study patients (67.8%) were treated with amino-salicylates (mesalamine and sulfasalazine), while azathioprine, steroids (prednisolone and budesonide), and biological therapy (infliximab and adalimumab), were prescribed for 44 (50.5%), 35 (40.2%), and 19 (21.8%) of cases, respectively. Recent PPI use was recorded in 7 cases (8%) while recent antibiotics exposure was recorded in 9 patients (10.3%). Recent hospitalization was recorded in 5 cases. The most common clinical presentations were bloody diarrhea and abdominal pain, that recorded in 51 (58.6%) and 45 (51.7%) of cases, respectively, followed by watery diarrhea in 34 (39%) and BPR in 9 (10.3%).According to the endoscopy, the most frequent underlying pathology was pancolitis in 34 patients (39%), followed by proctosigmoiditis in 24 (27.5%) and ileitis that seen in 20 patients (22.9%), while each of left sided colitis and proctitis were recorded in 11 (12.6%) and 8 (9.1%) of study patients respectively. The incidence of CDI among the 87 enrolled IBD patients was 20%, In the study, there was no statistically significant association between the developing of CDI and each of age (P= 0.601), gender (P= 0.998), use of PPI(P= 0.131), recent antibiotic exposure(P= 0.904), recent hospitalization(P= 0.968), type of IBD (P= 0.493), duration (P= 0.272), severity (P= 0.081), and endoscopic extend of the colitis (P= 0.713), on the other hand CDI is significantly associated (P= 0.002) with administration of multiple IBD drugs, as more than half of patients (53.3%) who treated with multiple drugs including immunosuppressive developed CDI. Conclusion: The current study showed that IBD patients on multiple immunosuppressive drugs have a higher risk for CDI development, yet no other risk factors have been identified in the current study(age, gender, antibiotic exposure, PPI use and recent hospitalization, in addition to disease duration, severity and endoscopic extend), Further larger study is needed to confirm these findings, to look for other possible risk factors and to evaluate treatment outcome.

clostridium difficile, inflammatory bowel disease, Risk factors, Pseudomembranous colitis

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