Low prevalence of Clostridioides difficile infection in acute severe ulcerative colitis: A retrospective cohort study from northern India.
Acute disease
Clostridioides
Clostridioides difficile toxin B
Colectomy
Colitis
Cytomegalovirus
Salvage therapy
Symptom flare up
Treatment outcome
Ulcerative colitis
Journal
Indian journal of gastroenterology : official journal of the Indian Society of Gastroenterology
ISSN: 0975-0711
Titre abrégé: Indian J Gastroenterol
Pays: India
ID NLM: 8409436
Informations de publication
Date de publication:
06 2023
06 2023
Historique:
received:
09
08
2022
accepted:
25
12
2022
medline:
19
7
2023
pubmed:
12
5
2023
entrez:
12
5
2023
Statut:
ppublish
Résumé
The incidence of Clostridioides difficile infection (CDI) is high in ulcerative colitis and is associated with disease flares and adverse outcomes. However, the data on the dynamics of CDI in patients with acute severe ulcerative colitis (ASUC) is rather scarce. We evaluated the prevalence of CDI in patients with ASUC. This retrospective analysis of a prospectively maintained cohort admitted to the All India Institute of Medical Sciences, India, from May 2016 to December 2021, included patients with ASUC (as per Truelove and Witts criteria) who were tested for CDI. CDI testing was performed using enzyme-linked immunoassay for toxins A and B. Risk factors for developing CDI were analyzed along with short-term outcomes of ASUC. Steroid failure was defined as the need for medical rescue therapy or colectomy. Total 153 patients with ASUC were included (mean age 34.92 ± 12.24 years; males 56.2%; disease duration 36 (IQR: 16-55.5) months, pancolitis 67.3%). Ninety-eight (63.4%), 72 (47%) and 10 (6.5%) patients, respectively, had received steroids, azathioprine and biologics in the past. Forty patients (26.14%) had a prior history of ASUC. Among risk factors for CDI, 14% of the patients had prior admission within 30 days, 22.2% had a recent history of antibiotics and 3.9% had long-term non-steroidal anti-inflammatory drug intake. Only one sample was positive for Clostridioides difficile toxin assay. Tissue Cytomegalovirus DNA-PCR positivity was noted in 57 patients (37.3%). Fifty-seven patients (37.3%) had steroid failure, 35 required medical rescue therapy and 30 (19.6%) required colectomy (eight after medical rescue therapy failure). Despite antecedent risk factors for CDI, the overall prevalence of CDI in ASUC was low and the outcomes were determined by underlying disease severity.
Sections du résumé
BACKGROUND
The incidence of Clostridioides difficile infection (CDI) is high in ulcerative colitis and is associated with disease flares and adverse outcomes. However, the data on the dynamics of CDI in patients with acute severe ulcerative colitis (ASUC) is rather scarce. We evaluated the prevalence of CDI in patients with ASUC.
METHODS
This retrospective analysis of a prospectively maintained cohort admitted to the All India Institute of Medical Sciences, India, from May 2016 to December 2021, included patients with ASUC (as per Truelove and Witts criteria) who were tested for CDI. CDI testing was performed using enzyme-linked immunoassay for toxins A and B. Risk factors for developing CDI were analyzed along with short-term outcomes of ASUC. Steroid failure was defined as the need for medical rescue therapy or colectomy.
RESULTS
Total 153 patients with ASUC were included (mean age 34.92 ± 12.24 years; males 56.2%; disease duration 36 (IQR: 16-55.5) months, pancolitis 67.3%). Ninety-eight (63.4%), 72 (47%) and 10 (6.5%) patients, respectively, had received steroids, azathioprine and biologics in the past. Forty patients (26.14%) had a prior history of ASUC. Among risk factors for CDI, 14% of the patients had prior admission within 30 days, 22.2% had a recent history of antibiotics and 3.9% had long-term non-steroidal anti-inflammatory drug intake. Only one sample was positive for Clostridioides difficile toxin assay. Tissue Cytomegalovirus DNA-PCR positivity was noted in 57 patients (37.3%). Fifty-seven patients (37.3%) had steroid failure, 35 required medical rescue therapy and 30 (19.6%) required colectomy (eight after medical rescue therapy failure).
CONCLUSION
Despite antecedent risk factors for CDI, the overall prevalence of CDI in ASUC was low and the outcomes were determined by underlying disease severity.
Identifiants
pubmed: 37171781
doi: 10.1007/s12664-022-01336-2
pii: 10.1007/s12664-022-01336-2
doi:
Substances chimiques
Steroids
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
411-417Informations de copyright
© 2023. Indian Society of Gastroenterology.
Références
Balram B, Battat R, Al-Khoury A, et al. Risk factors associated with clostridium difficile infection in inflammatory bowel disease: a systematic review and meta-analysis. J Crohns Colitis. 2019;13:27–38.
doi: 10.1093/ecco-jcc/jjy143
pubmed: 30247650
Sokol H, Lalande V, Landman C, et al. Clostridium difficile infection in acute flares of inflammatory bowel disease: A prospective study. Dig Liver Dis. 2017;49:643–6.
doi: 10.1016/j.dld.2017.01.162
pubmed: 28215602
Khanna S. Management of Clostridioides difficile infection in patients with inflammatory bowel disease. Intest Res. 2021;19:265–74.
doi: 10.5217/ir.2020.00045
pubmed: 32806873
Fernandopulle ANR, Mayadunne PB, Navarathne NMM. The prevalence of Clostridium difficile infection in a cohort of Sri Lankan patients with acute severe ulcerative colitis. Gastroenterol Hepatol Open Access. 2014;1:00008.
Navaneethan U, Mukewar S, Venkatesh PG, Lopez R, Shen B. Clostridium difficile infection is associated with worse long term outcome in patients with ulcerative colitis. J Crohns Colitis. 2012;6:330–6.
Kariv R, Navaneethan U, Venkatesh PG, Lopez R, Shen B. Impact of Clostridium difficile infection in patients with ulcerative colitis. J Crohns Colitis. 2011;5:34–40.
Nguyen GC, Kaplan GG, Harris ML, Brant SR. A national survey of the prevalence and impact of Clostridium difficile infection among hospitalized inflammatory bowel disease patients. Am J Gastroenterol. 2008;103:1443–50.
doi: 10.1111/j.1572-0241.2007.01780.x
pubmed: 18513271
Clayton EM, Rea MC, Shanahan F, et al. The vexed relationship between Clostridium difficile and inflammatory bowel disease: An assessment of carriage in an outpatient setting among patients in remission. Am J Gastroenterol. 2009;104:1162–9.
doi: 10.1038/ajg.2009.4
pubmed: 19319128
Jodorkovsky D, Young Y, Abreu MT. Clinical outcomes of patients with ulcerative colitis and co-existing Clostridium difficile infection. Dig Dis Sci. 2010;55:415–20.
doi: 10.1007/s10620-009-0749-9
pubmed: 19255850
Ghia CJ, Waghela S, Rambhad GS. Systematic literature review on burden of Clostridioides difficile infection in India. Clin Pathol. 2021;14:2632010X211013816.
Chaudhry R, Joshy L, Kumar L, Dhawan B. Changing pattern of Clostridium difficile associated diarrhoea in a tertiary care hospital: A 5-year retrospective study. Indian J Med Res. 2008;127:377–82.
pubmed: 18577793
Chaudhry R, Sharma N, Gupta N, et al. Nagging presence of Clostridium difficile associated diarrhoea in North India. J Clin Diagn Res. 2017;11:DC06-DC09.
Kochhar R, Ayyagari A, Goenka MK, Dhali GK, Aggarwal R, Mehta SK. Role of infectious agents in exacerbations of ulcerative colitis in India. A study of Clostridium difficile. J Clin Gastroenterol. 1993;16:26–30.
doi: 10.1097/00004836-199301000-00008
pubmed: 8421140
Vaishnavi C, Kochhar R, Bhasin D, Thennarasu K, Singh K. Simultaneous assays for Clostridium difficile and faecal lactoferrin in ulcerative colitis. Trop Gastroenterol. 2003;24:13–6.
pubmed: 12974208
Iyer VH, Augustine J, Pulimood AB, Ajjampur SS, Ramakrishna BS. Correlation between coinfection with parasites, cytomegalovirus, and Clostridium difficile and disease severity in patients with ulcerative colitis. Indian J Gastroenterol. 2013;32:115–8.
doi: 10.1007/s12664-012-0302-1
pubmed: 23408260
Sethi SS, Puri AS, Sachdeva S, Dalal A. Clostridium difficile superinfection in patients with ulcerative colitis in India: A poorly recognized pathogen associated with disease flare. Indian J Gastroenterol. 2018;37:1–137.
Ghoshal U, Singh R, Tejan N, Verma A, Ghoshal UC. Prevalence and molecular characterization of Clostridium difficile in patients with inflammatory bowel disease in a university hospital in northern India. J Gastroenterol Hepatol. 2019;34Suppl 3:247.
Regnault H, Bourrier A, Lalande V, et al. Prevalence and risk factors of Clostridium difficile infection in patients hospitalized for flare of inflammatory bowel disease: A retrospective assessment. Dig Liver Dis. 2014;46:1086–92.
doi: 10.1016/j.dld.2014.09.003
pubmed: 25294795
Le Baut G, Kirchgesner J, Amiot A, et al. A scoring system to determine patients’ risk of colectomy within 1 year after hospital admission for acute severe ulcerative colitis. Clin Gastroenterol Hepatol. 2021;19:1602–10.
doi: 10.1016/j.cgh.2019.12.036
pubmed: 31927106
Law CC, Tariq R, Khanna S, Murthy S, McCurdy JD. Systematic review with meta-analysis: The impact of Clostridium difficile infection on the short- and long-term risks of colectomy in inflammatory bowel disease. Aliment Pharmacol Ther. 2017;45:1011–20.
doi: 10.1111/apt.13972
pubmed: 28206678
Jain S, Kedia S, Bopanna S, et al. Faecal calprotectin and UCEIS predict short-term outcomes in acute severe colitis: Prospective cohort study. J Crohns Colitis. 2017;11:1309–16.
doi: 10.1093/ecco-jcc/jjx084
pubmed: 29088461
Jain S, Namdeo D, Sahu P, et al. High mucosal cytomegalovirus DNA helps predict adverse short-term outcome in acute severe ulcerative colitis. Intest Res. 2021;19:438–47.
doi: 10.5217/ir.2020.00055
pubmed: 33147897
Zagórowicz E, Bugajski M, Wieszczy P, Pietrzak A, Magdziak A, Mróz A. Cytomegalovirus infection in ulcerative colitis is related to severe inflammation and a high count of cytomegalovirus-positive cells in biopsy is a risk factor for colectomy. J Crohns Colitis. 2016;10:1205–11.
doi: 10.1093/ecco-jcc/jjw071
pubmed: 26971053
Li Y, Xu H, Xu T, et al. Case-control study of inflammatory bowel disease patients with and without Clostridium difficile infection and poor outcomes in patients coinfected with C. difficile and cytomegalovirus. Dig Dis Sci. 2018;63:3074–83.
doi: 10.1007/s10620-018-5230-1
pubmed: 30094621
pmcid: 6182452
Xu H, Tang H, Xu T, et al. Retrospective analysis of Clostridium difficile infection in patients with ulcerative colitis in a tertiary hospital in China. BMC Gastroenterol. 2019;19:3.
doi: 10.1186/s12876-018-0920-x
pubmed: 30616563
pmcid: 6323708
Chen XL, Deng J, Chen X, Wan SS, Wang Y, Cao Q. High incidence and morbidity of Clostridium difficile infection among hospitalized patients with inflammatory bowel disease: A prospective observational cohort study. J Dig Dis. 2019;20:460–6.
doi: 10.1111/1751-2980.12798
pubmed: 31278840
Kim DB, Lee KM, Park SH, et al. Is Clostridium difficile infection a real threat in patients with ulcerative colitis? A prospective, multicenter study in Korea. Intest Res. 2018;16:267–72.
doi: 10.5217/ir.2018.16.2.267
pubmed: 29743839
pmcid: 5934599
Monaghan TM, Biswas R, Satav A, Ambalkar S, Kashyap RS. Clostridioides difficile epidemiology in India. Anaerobe. 2022;74:102517.
doi: 10.1016/j.anaerobe.2022.102517
pubmed: 35063600
Klein EY, Van Boeckel TP, Martinez EM, et al. Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proc Natl Acad Sci U S A. 2018;115:E3463–70.
doi: 10.1073/pnas.1717295115
pubmed: 29581252
pmcid: 5899442
Segar L, Easow JM, Srirangaraj S, Hanifah M, Joseph NM, Seetha KS. Prevalence of Clostridium difficile infection among the patients attending a tertiary care teaching hospital. Indian J Pathol Microbiol. 2017;60:221–5.
doi: 10.4103/0377-4929.208383
pubmed: 28631639
Balamurugan R, Balaji V, Ramakrishna BS. Estimation of faecal carriage of Clostridium difficile in patients with ulcerative colitis using real time polymerase chain reaction. Indian J Med Res. 2008;127:472–7.
pubmed: 18653911
Kim YS, Kim YH, Kim JS, et al. Long-term outcomes of cytomegalovirus reactivation in patients with moderate to severe ulcerative colitis: A multicenter study. Gut Liver. 2014;8:643–7.
doi: 10.5009/gnl13427
pubmed: 25368753
pmcid: 4215451
Al-Zafiri R, Gologan A, Galiatsatos P, Szilagyi A. Cytomegalovirus complicating inflammatory bowel disease: A 10-year experience in a community-based, university-affiliated hospital. Gastroenterol Hepatol (N Y). 2012;8:230–9.
pubmed: 22723754
Kelly CR, Fischer M, Allegretti JR, et al. ACG clinical guidelines: Prevention, diagnosis, and treatment of Clostridioides difficile infections. Am J Gastroenterol. 2021;116:1124–47.
doi: 10.14309/ajg.0000000000001278
pubmed: 34003176