Clostridium difficile Infection in Inflammatory Bowel Disease Patients: Influence of Antibiotic Choice on Adverse Outcomes

Abstract

Introduction: Inflammatory bowel disease (IBD) is an independent risk for developing Clostridium difficile infection (CDI), which often precipitates an IBD flare. The influence of CDI treatment on IBD outcomes is not well understood. We evaluated the outcomes of CDI treatment in IBD patients to identify factors associated with adverse outcomes. Methods: Data abstracted from patients with IBD and CDI from 2008 to 2013 included CDI severity and management as well as rates of subsequent CDI episodes, CDI-related hospitalizations, IBD flares and colectomy at 1 year. Severe CDI was defined as WBC >15,000/μL or serum creatinine ≥ 1.5 times baseline and severe complicated was defined as hypotension, shock, ileus, megacolon, bowel perforation, ICU admission or bowel resection for IBD management at the time of active CDI. Subsequent CDI episodes were defined as return of symptoms with a positive stool test after completing CDI therapy. IBD flares post-CDI were defined as symptom recurrence, exacerbation or persistence with negative stool CDI. Statistical analyses comprised of descriptive statistics and one-way ANOVA. Results: Overall, 137 IBD patients (median age, 46.4 years; 55% female) were included; 51% with ulcerative colitis, 46% with Crohn's disease & 3% with indeterminate colitis. Infections were classified as mild-moderate (71%), severe (14%) and severe complicated (15%). Table 1 shows CDI severity and outcomes by CDI treatment regimen. About 40% of CDI from each severity cohort was treated with metronidazole. Treatment with both vancomycin and metronidazole was the second most commonly used regimen for severe or severe complicated CDI. No significant difference was observed among the different CDI treatments and infection severity (p=0.27). Further, CDI treatment choice did not significantly influence the rate of subsequent CDI (p=0.56), CDI-related hospitalization (p=0.15), IBD flare (p=0.54), or colectomy (p=0.42) 1 year post-CDI.Table. CDI: Severity and Outcomes by Antibiotic RegimenConclusion: IBD patients with CDI were most commonly treated with only metronidazole for their infection. The type or combination of antibiotics to treat CDI in these patients did not influence the rate of adverse events of subsequent CDI, CDI-related hospitalization, IBD flares, or colectomy at 1 year follow-up. There was no relationship between CDI severity and type of antibiotic regimen among IBD patients. Prospective studies are needed to further elucidate optimal CDI management in this high-risk group.