Clostridium difficileand inflammatory bowel disease: Role in pathogenesis and implications in treatment

Abstract

Clostridium difficile (C. difficile) is the leading cause of antibiotic associated colitis and nosocomial diarrhea. Patients with inflammatory bowel disease (IBD) are at increased risk of developing C. difficile infection (CDI), have worse outcomes of CDI-including higher rates of colectomy and death, and experience higher rates of recurrence. However, it is still not clear whether C. difficile is a cause of IBD or a consequence of the inflammatory state in the intestinal environment. The burden of CDI has increased dramatically over the past decade, with severe outbreaks described in many countries, which have been attributed to a new and more virulent strain. A parallel rise in the incidence of CDI has been noted in patients with IBD. IBD patients with CDI tend be younger, have less prior antibiotic exposure, and most cases of CDI in these patients represent outpatient acquired infections. The clinical presentation of CDI in these patients can be unique-including diversion colitis, enteritis and pouchitis, and typical findings on colonoscopy are often absent. Due to the high prevalence of CDI in patients hospitalized with an IBD exacerbation, and the prognostic implications of CDI in these patients, it is recommended to test all IBD patients hospitalized with a disease flare for C. difficile. Treatment includes general measures such as supportive care and infection control measures. Antibiotic therapy with either oral metronidazole, vancomycin, or the novel antibiotic-fidaxomicin, should be initiated as soon as possible. Fecal macrobiota transplantation constitutes another optional treatment for severe/recurrent CDI. The aim of this paper is to review recent data on CDI in IBD: role in pathogenesis, diagnostic methods, optional treatments, and outcomes of these patients.

Fecal Microbiota Transplantation in Recurrent Clostridium Difficile Infections: Our Experience in Patients with and without Inflammatory Bowel Disease

“…Similar gut dysbiosis that occurs in antibiotic use, has also been found in patients with IBD [4]. It is well established that patients with IBD have a higher incidence of CDI than the average population [1,5,7].…”

“…Keywords: Recurrent clostridium difficile infection; Fecal microbiota transplantation; Inflammatory bowel disease therapy for patients with recurrent disease to reintroduce typical microbiota and reestablish balance [1,3,5].…”

“…The gastrointestinal tract harbors approximately 100 trillion bacterial cells that exist symbiotically to maintain the integrity of the intestinal mucosa and the gut immune system [1,2]. Intestinal homeostasis is achieved by the symbiotic relationship between the host immune system and these microbes.…”

“…Recent studies have established the role of environmental factors (such as diet, antibiotic use, and NSAID use), and their effect on the gut microbiome in the development of inflammatory bowel disease (IBD) in genetically susceptible individuals [1,5]. Ulcerative colitis (UC) is characterized by continuous inflammatory changes of the superficial layers of the colon, while Crohn's disease (CD) is characterized by transmural inflammation that can affect any area of the gastrointestinal tract in a patchy manner [6].…”

“…Of the 9 patients treated with FMT with concurrent IBD, all reported resolution of diarrhea and improvement in abdominal pain initially with FMT. Further studies are needed to assess these patients long term benefits after FMT and correlation with IBD flares as well.Keywords: Recurrent clostridium difficile infection; Fecal microbiota transplantation; Inflammatory bowel disease therapy for patients with recurrent disease to reintroduce typical microbiota and reestablish balance [1,3,5].One longstanding theory of IBD pathogenesis includes disruption of the intestinal wall and immune dysregulation against altered commensal gut bacteria [6]. Patients with IBD are highly susceptible to CDI due to immunosuppressive agents used for treatment, intermittent hospital courses, and altered gut microbiota as well [7].…”