Abstract
Background
Inflammatory bowel disease (IBD) is a recognised risk factor for clostridium difficile infection (CDI), and CDI in an IBD patient is associated with higher morbidity and mortality. It is thought that factors including alterations in the gut microbiome, mucosal disruption and immunosuppression provide a synergistic environment for CDI to complicate an IBD flare. Despite this, there is conflicting evidence available on management. Our aim was to examine a series of recent cases to assess our own practice and subsequent outcomes.
Methods
A retrospective analysis was carried out of hospitalised cases of CDI in IBD patients in Greater Glasgow and Clyde from 2017 to 2018. Patients were identified via the CDI database held by the microbiology department; those with co-existing IBD were extrapolated. Data collected included demographics, IBD subtype and presence of other CDI risk factors. Severity of symptoms was assessed using Truelove and Witts Criteria. Initial management and changes following the diagnosis of CDI were noted. Outcomes were measured by the length of stay, survival to discharge, and requirement for surgical intervention. One year outcomes were assessed by recording mortality, treatment escalation and re-admission to hospital.
Results
29 patients in total were identified (61% female, 39% male). Twenty-one had a diagnosis of ulcerative colitis, 7 Crohn’s disease, and 1 IBD unclassified. Twenty-four were on immunosuppressive therapy at the time of CDI, 11 were on dual or triple immunosuppression. This was continued during admission in all but three cases. Once the diagnosis of CDI was established, metronidazole was given in 16 cases and vancomycin in 13. Steroid treatment varied - 13 received oral steroids, 5 IV steroids and 11 no steroids. There was no clear correlation between steroid management and outcome. Assessment with the Travis criteria on day 3 indicated a high chance of colectomy in 12 patients, however only one required surgical intervention. No patients received a faecal transplant. The median length of stay was 15 days (range 3–169). One patient did not survive to discharge.
In those surviving to discharge, a further 6 had died at one year, bringing the one-year mortality to 24%. Three had CDI as a contributory factor listed on the death certificate. 31% of surviving patients had their IBD treatment escalated in the year following admission, 17% were treated for CDI relapse, and 28% had readmission to hospital.
Conclusion
Managing CDI in patients with co-existing IBD is challenging. This case series highlights the lack of consensus on how this should be approached, even within a single health board. Morbidity and mortality are high. This suggests that a wider body of work is required to establish guidelines and provide better outcomes.
Antibiotics for Treatment of Clostridium difficile Infection in Hospitalized Patients with Inflammatory Bowel Disease