Sa2064 Probiotics Associated With Higher Rates of Subsequent Clostridium difficile Infection in Inflammatory Bowel Disease Population

Abstract

Introduction:There has been an increased rate of Clostridium difficile infection (CDI) with disproportionately higher impact on the inflammatory bowel disease (IBD) populationCrohn's disease (CD) and Ulcerative Colitis (UC). Treatment protocol has traditionally consisted of vancomycin or metronidazole. The outcome of probiotic treatment in this unique population is not defined. We sought to evaluate the impact of probiotics on rates of subsequent CDI and disease course. Methods:This was a retrospective observational study of all IBD pts followed at a single IBD center with CDI confirmed by suggestive gastrointestinal symptoms and either positive toxin A/B ELISA stool test or nucleic acid amplification stool test (NAAT). Pt demographics and disease characteristics were collected. We evaluated the performance of probiotics used by assessing rate of subsequent CDI over the following year. Probiotic used was Florajen (reported to have 20 billion live, freeze dried, human source strains of lactobacillus acidophilus). IBD clinical course the year following CDI was evaluated using inflammatory markers, corticosteroid usage, and disease related complications including hospitalizations and surgeries. Results:There were 101 IBD (62 CD, 39 UC) pts who had CDI confirmed (35 inpts and 66 outpts). 31 IBD pts (20 CD, 11 UC) with CDI were in the probiotic group (P) and 70 IBD pts (42 CD and 28 UC) were in the control group (C). There was no difference in disease duration, IBD maintenance therapy, disease type/ behavior between these groups. Initial antibiotic therapy used for treatment of CDI was metronidazole (M) in 48 pts, vancomycin (V) in 38 pts and combination of metronidazole + vancomycin (M+V) in 15 pts. The rate of subsequent CDI (>1) over the following year was 39% (12/31pts) in P group and 16% (11/70pts) in the C group (p=0.01). Probiotic treatment rates were 15% (7/48) in the M group, 42% (16/38) in the V group, and 53% (8/15) in the M+V group. There was a higher rate of probiotic treatment in the V group compared with the M group (42% vs 15%; p=0.04) and in the M+V group compared with the M group (15% vs 53%; p=0.002). There was no difference in probiotic use between V andM+V groups (42% vs 53%; p=0.46). Recurrence rate was not affected by IBDmaintenance therapy (biologic/immunomodulator or both). Antibiotic used in initial CDI had no impact on rate of hospitalizations, IBD related surgeries or mean ESR and CRP values over the following year. Conclusions:In our cohort, use of lactobacillus acidophilus single strain probiotic during initial CDI was associated with higher rates of subsequent CDI. Probiotic usage was higher in the CDI treatment groups with vancomycin alone and in combination with metronidazole. Further studies are necessary to define appropriate roles for probiotic strains in combination with antibiotics for preventing CDI recurrence.