Inflammatory bowel disease (IBD) increases the risk and severity of Clostridium difficile infection (CDI) while CDI tends to complicate and worsen the clinical course of IBD, experts note in a clinical practice update.

Thus, it is crucial that clinicians pursue stool testing for toxigenic C. difficile infection whenever a patient with IBD presents with a colitis flare, regardless of the recent antibiotic history, wrote Sahil Khanna, MBBS, of the Mayo Clinic, Rochester, Minn., and his associates (Clin Gastroenterol Hepatol. 2016 Feb. doi: 10.1016/j.cgh.2016.10.024). Clinicians should also test for recurrent CDI if symptoms of colitis persist or return after antibiotic therapy for CDI, they emphasized.

CDIs are on the rise and now cause about 29,000 deaths annually in the United States, surpassing the combined death count from methicillin-resistant Staphylococcus aureus and multidrug resistant gram-negative bacteria. Reasons for this concerning trend include rising antibiotic use, population aging, and the emergence of highly virulent C. difficile strains. Patients with CDI and underlying IBD are at particular risk of hospitalization, intensification of medical therapies for IBD, and surgery. Rates of CDI have risen among both the ulcerative colitis and Crohn’s disease populations, but are higher in the setting of ulcerative colitis, perhaps because these patients are more likely to have colonic dysbiosis.

CDI can present atypically in IBD. Underlying colitis leads to colonic dysbiosis and loss of resistance to bacterial colonization, which permits CDI to develop even when patients have not recently received antibiotics. Patients with IBD also tend to develop CDI starting at younger ages, more often acquire it from community settings, and may lack the typical colonoscopic features of CDI. Simple colonization of C. difficile without infection also is more common in patients with IBD than in those without IBD, the experts note.

The authors contradict guidelines from both the American College of Gastroenterology and Infectious Diseases Society of America by recommending consideration of vancomycin over metronidazole for treatment of CDI. Not only are C. difficile treatment failures with metronidazole rising, but vancomycin was more effective than was metronidazole in a recent post hoc analysis ( Clin Infect Dis. 2014;59[3]:345-54 ) of two large multicenter phase III trials. Furthermore, another phase III trial ( N Engl J Med. 2011;364:422-31 ) found vancomycin noninferior to fidaxomicin for CDI.

The experts recommend “strong consideration” of hospitalization if patients with IBD and CDI present with profuse diarrhea, severe abdominal pain, a markedly increased peripheral blood leukocyte count, or other signs and symptoms of sepsis. Aggressive monitoring and treatment are especially important because it can be difficult to distinguish an IBD flare, which merits immunosuppression, from superimposed CDI, which might exacerbate the underlying infection, they noted. Few studies are available to help guide the decision about when to intensify steroids and other immunosuppressives in IBD patients with acute CDI. Thus, the experts suggest delaying this step until after starting therapy for CDI, but note that this decision should be individualized pending more robust data.

The authors emphasized the potential role of fecal microbiota transplantation (FMT), which has been shown to be very effective in both immunocompetent patients with CDI and those who are immunosuppressed, including because of IBD therapies. They recommend considering referral for FMT as early as the first recurrence of CDI in patients with IBD, particularly because of the strong safety and efficacy profile of FMT, the risk of complications from CDI in IBD patients, and scarce data on antibiotic therapy for recurrent CDI in the setting of IBD.

Dr. Khanna disclosed consulting relationships with Rebiotix. and Summit Pharmaceuticals. Senior author Ciaran P. Kelly, MD, disclosed serving as a consultant to Merck, Seres Therapeutics, Summit Pharmaceuticals, and Takeda Pharmaceuticals. The third author, Andrea Shin, MD, had no relevant disclosures.


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