Crohnʼs Disease, Antibiotic Use, and Recent Health Care Exposures Are Associated with Clostridium difficile Isolation in IBD

Abstract

Introduction:Clostridium difficile is the most commonly isolated stool pathogen in inflammatory bowel disease (IBD). Although previous studies have identified risk factors for the isolation of C. difficile in the setting of clinically active IBD, no studies have assessed the risk factors for the isolation of C. difficile in both symptomatic and asymptomatic IBD outpatients. Methods: We recruited consecutive IBD patients presenting to our outpatient clinic between April 1 and August 1, 2015. Demographics, healthcare exposures, need for medical and surgical therapies and disease activity were recorded from prospectively completed surveys. Asymptomatic disease was defined by a Harvey Bradshaw Index 4 or Simple Colitis Activity Index 2. Self-reported dietary intake was performed. A rectal swab was performed from which toxigenic culture, PCR toxin analysis and PCR-ribotyping was performed. The primary outcome of interest was isolation of C. difficile. Data were analyzed with Student's t-tests for continuous variables and chi-squared analysis for dichotomous variable. Results: One hundred thirty-five patients were included in this study (67% Crohn's disease) of which 82 (61%) were clinically asymptomatic. C. difficile was isolated from 10 patients (7.4%) of which 6 patients were asymptomatic. Among the C. difficile strains isolated, 7 were toxin-producing strains and 3 were non-toxigenic. Hypervirulent ribotypes (027/078) were not isolated in this population. Factors associated with the isolation of C. difficile among all IBD patients are listed in Table 1. Significant factors include Crohn's disease diagnosis, recent antibiotic use and healthcare exposures. Among asymptomatic IBD patients, Crohn's disease diagnosis and history of IBD hospitalization were associated with the isolation of C. difficile (Table 2). Daily self-reported intake of fruit was associated with a decreased risk of C. difficile isolation in both the entire cohort and asymptomatic IBD populations (P = 0.05 and 0.02, respectively). Probiotic use was associated with an increased risk of C. difficile isolation in the asymptomatic population (P = 0.004).Table 1: Factors associated with the isolation of C. difficile among all IBD patientsTable 2: Factors associated with the isolation of C. difficile among asymptomatic IBD patientsConclusion: This is the largest study to assess risk factors for the isolation of C. difficile among both symptomatic and asymptomatic outpatients with IBD. Crohn's disease diagnosis, antibiotic use and healthcare exposures were associated with an increased risk for isolation of C. difficile, while intake of fruits was associated with a reduced risk.