Prevalence and Management of C. difficile Infection in Inflammatory Bowel Disease Outpatient and Inpatient Setting at a Tertiary Care Center

Abstract

Introduction: The purpose of this study was to compare prevalence of C. difficile I infection (CDI) in an inflammatory bowel disease (IBD) population, assess risk factors contributing to CDI in IBD and compare management strategies (antibiotics used). Currently, there are no specific guidelines to treat CDI in IBD patients. Methods: A retrospective chart review was done on all patients who had clinic visits and inpatient hospitalizations with diagnosis of IBD and CDI extracted from Centricity and Amalga electronic medical records dating from January 2007 to March 2013. Recurrence was defined as repeat infection with CDI within 6 months after treatment and symptom-free period. Results: A total of 89 IBD patients presented to the clinic with primary concern of acute IBD flare between 2007 and 2013. Eleven patients (12%) tested positive for CDI. Five patients were on oral steroids and 4 were on immunomodulators. Six patients had ulcerative colitis (UC), and 5 had Crohn’s disease (CD). Four patients had both small bowel (SB) and large bowel (LB), 3 patients had left sided LB disease, 3 had pancolitis (PC), and 1 had SB only disease. Two patients had recurrence of CDI within 6 months of treatment. A total of 51 IBD patients were admitted to the hospital for acute IBD flare with a total of 91 different hospitalizations. 12/51 (23%) patients tested positive for CDI. Six patients positive for CDI were on oral steroids, and 7 were on immunomodulators. Seven patients had CD, and 5 had UC. Seven patients had PC, 4 had left sided LB disease; 1 had both SB and LB. All 12 patients had moderate to severe disease seen endoscopically at the time of diagnosis. All 12 patients were treated with oral vancomycin and IV metronidazole combination for the first 3 days followed by oral vancomycin and oral metronidazole combination for 12 additional days. The average inpatient hospital stay was 4 days with all 12 patients successfully discharged from the hospital resulting in no mortality. Conclusion: Prevalence of CDI in IBD population has increased significantly in last decade. Studies have shown steroids and colonic disease to be risk factors for CDI. Our study revealed CDI in the SB of a UC patient after proctocolectomy. Medications including steroids, immunomodulators, and biologics might be contributing risk factors. CDI are associated with higher morbidity, mortality, and increased number of hospitalizations in the IBD population. Our study showed that a significant number of patients admitted for acute IBD flare had CDI with average hospital stay of 4 days. We propose that CDI can be treated successfully in both settings if recognized early and treated aggressively with combination therapy of metronidazole and oral vancomycin.