Low Rate of Clostridium difficile Infection Testing in Patients with Newly Diagnosed Inflammatory Bowel Disease and Diarrhea

Abstract

Purpose:Clostridium difficile infection (CDI) has been reported in patients with inflammatory bowel disease (IBD) in the community and during hospitalization, and may occur in IBD without exposure to antibiotics. The rate of CDI in patients with and without IBD has increased over the last decade. CDI is associated with various adverse outcomes in IBD, including disease relapse, colectomy (in ulcerative colitis), hospitalization and mortality. Thus, testing for CDI in patients with diarrhea and IBD is considered standard of care. Little data exist regarding the prevalence of CDI in newly diagnosed IBD, and its effect on disease course. As a basis for future studies to determine the impact of CDI on the course of IBD, we sought to determine rate of CDI and CDI testing at diagnosis of IBD. Methods: Rhode Island patients diagnosed with IBD after January 2008 and within one year of diagnosis were eligible to enroll in the Ocean State Crohn's and Colitis Area Registry (OSCCAR), a prospective cohort started January 2008. Medically trained personnel confirmed diagnosis of IBD by chart review using standard criteria. All patients completed a questionnaire regarding symptoms at diagnosis. This included self-report of diarrhea (loose or watery bowel movements and/or increased frequency of stool) within 4 weeks before diagnosis of IBD. Trained data abstractors recorded occurrence of CDI toxin or PCR assay testing and results from medical records of the gastroenterologist and/or surgeon who reported a new diagnosis, or inpatient records if diagnosed during hospitalization. Results: Among 338 patients enrolled from January 2008 to June 2011, 260 (76.9%) reported diarrhea. Of the 260 patients, results of CDI testing were recorded in diagnosing physicians' records for 120 patients (46.2%). CDI testing was not recorded or possibly not performed for the remaining 140 patients who presented with diarrhea. An additional 21 patients were tested for CDI but did not report having diarrhea or did not have a symptom inventory on record. Of the 141 patients tested for CDI, 74 were female; 65 were diagnosed with ulcerative colitis, 65 with Crohn's disease, and 11 patients had IBD undetermined. Seven (4.9%) of the 141 patients tested were positive for CDI (2.1% of all patients). Conclusion: Testing for CDI is lower than expected at diagnosis of IBD especially among patients who presented with diarrhea. Although the prevalence of CDI among tested patients is only ˜5%, low rate of testing and possible delayed diagnosis of CDI in newly diagnosed IBD may be a significant quality issue. A limitation of the study is that we are unable to determine whether CDI testing was done prior to specialty referral and thus we may underestimate the rate of CDI testing.