Two decades ago, CDI was considered uncommon among IBD patients, even among those presenting with a disease flare up. In fact, some studies questioned the relevance of routinely looking for C difficileas an inciting pathogen among patients with an IBD flare up. More recently, published literature has confirmed a rising incidence and excess morbidity and mortality associated with CDI in IBD patients.
Research has shown that IBD patients with colitis appear to be at greater risk for acquiring CDI. These individuals are at greater risk for poor clinical outcomes, including colectomy and death, when compared with the general population. In addition, CDI has been associated with a significant increase in healthcare utilization and costs. Length of hospitalization has been identified as a risk factor for acquisition of C difficile. CDI itself may be associated with a 40% to 60% increase in length-of-stay and hospitalization costs. In a recent analysis, my colleagues and I found that CDI is associated with a 3-day excess hospitalization stay and more than $11,000 in hospitalization charges.
“It’s important for treating clinicians to have a high suspicion index for CDI in IBD patients.”
Treatment Challenges Persist
Older age and comorbidity are well-recognized risk factors for CDI, but we now have several reports of CDI among younger, healthy outpatients. Both CDI and IBD flares often present with similar symptoms but have markedly divergent management plans. When IBD is present and immunosuppressive drugs are required, it can be challenging to achieve an immunologic response to C difficile toxins. This is important because it may represent a critical mechanism for eradicating CDI and establishing stable colonization. Treatment of CDI in IBD requires directed antibiotic therapy and minimizing immunosuppression, particularly with corticosteroids. Conversely, the management of an IBD flare involves escalation in immunosuppressive therapy. As such, it’s important for treating clinicians to have a high suspicion index for CDI in IBD patients. Clinicians are recommended to initiate early testing and appropriate antibiotic therapy in order to positively impact both short- and long-term outcomes.
Infection Control is Necessary
There is high potential for the transfer of CDI between patients, particularly within the hospital and through healthcare providers. Clinicians must follow appropriate infection control and hygiene policies when managing patients with proven or suspected CDI because these spores are often resistant to treatment. Alcohol-based hand gels have had little to no effect on the vegetative spores of C difficile. Instead, use of disposable gloves and thorough hand washing with soap and water is recommended before and after contact with these patients. Chlorhexidine hand washes may also be as effective as soap and water washes. Isolation of patients with suspected or diagnosed CDI should be followed, along with the use of gowns and gloves for all patient contact.
More Research is Needed
There is a strong need for multi-dimensional studies to better define risk factors for CDI among IBD patients. We also need to better understand how disease activity and ongoing therapy influences the risks of CDI and a better grasp on absolute risks for specific patient subgroups. A more pressing need is to identify optimal diagnosis and treatment algorithms. Comparative effectiveness studies of therapies that are used for initial episodes of CDI and recurrences would also be of benefit. It’s also unclear how to manage immunosuppressive therapy in patients with a disease flare triggered by active CDI. The hope is that we’ll establish more effective means for managing these patients as more research and randomized controlled trials are conducted.
Readings & Resources (click to view)
Ananthakrishnan AN, Binion DG. Impact of Clostridium difficile on inflammatory bowel disease. Expert Rev Gastroenterol Hepatol. 2010;4:589-600.
Ananthakrishnan AN, Issa M, Binion DG. Clostridium difficile and inflammatory bowel disease.Gastroenterol Clin North Am. 2009;38:711-728.
Ananthakrishnan AN, McGinley EL, Binion DG. Excess hospitalisation burden associated withClostridium difficile in patients with inflammatory bowel disease. Gut. 2008;57:205-210.
Kuijper EJ, Coignard B, Tull P. Emergence of Clostridium difficile-associated disease in North America and Europe. Clin Microbiol Infect. 2006;12(Suppl 6):2-18.