Skip to main content

Advertisement

Log in

Clostridium difficile Infection in Patients with Inflammatory Bowel Disease

  • Intra-abdominal Infections, Hepatitis, and Gastroenteritis (T Steiner, Section Editor)
  • Published:
Current Infectious Disease Reports Aims and scope Submit manuscript

Abstract

Clostridium difficile infection (CDI) is now the leading cause of nosocomial infection. There has been an upsurge of CDI in patients with inflammatory bowel disease (IBD). IBD patients with CDI have increased morbidity and mortality. The establishment, proliferation, and recurrence of CDI in IBD patients form a complex interplay of microbial, environmental, and host-susceptibility factors. Different risk factors have been found predisposing IBD patients to CDI. Vancomycin performs better than metronidazole in treating IBD patients with CDI. Fecal microbiota transplantation continues to be a very effective therapy. New therapeutic modalities such as vaccinations and bile salts are currently being investigated.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Halabi WJ, Nguyen VQ, Carmichael JC, Pigazzi A, Stamos MJ, Mills S. Clostridium difficile colitis in the United States: a decade of trends, outcomes, risk factors for colectomy, and mortality after colectomy. J Am Coll Surg. 2013;217(5):802–12.

    Article  PubMed  Google Scholar 

  2. Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care–associated infections. N Engl J Med. 2014;370:1198–208.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Cosnes J, Gower–Rousseau C, Seksik P, Cortot A. Epidemiology and natural history of inflammatory bowel diseases. Gastroenterology. 2011;140(6):1785–94.

    Article  PubMed  Google Scholar 

  4. Ricciardi R, Ogilvie Jr JW, Roberts PL, Marcello PW, Concannon TW, Baxter NN. Epidemiology of Clostridium difficile colitis in hospitalized patients with inflammatory bowel diseases. Dis Colon Rectum. 2009;52(1):40–5.

    Article  PubMed  Google Scholar 

  5. 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(6):1443–50.

    Article  PubMed  Google Scholar 

  6. Ananthakrishnan AN, McGinley EL, Saeian K, Binion DG. Temporal trends in disease outcomes related to Clostridium difficile infection in patients with inflammatory bowel disease. Inflamm Bowel Dis. 2011;17(4):976–83.

    Article  PubMed  Google Scholar 

  7. Rodemann JF, Dubberke ER, Reske KA, da Seo H, Stone CD. Incidence of Clostridium difficile infection in inflammatory bowel disease. Clin Gastroenterol Hepatol. 2007;5(3):339–44.

    Article  PubMed  Google Scholar 

  8. Issa M, Vijayapal A, Graham MB, et al. Impact of Clostridium difficile on inflammatory bowel disease. Clin Gastroenterol Hepatol. 2007;5(3):345–51.

    Article  PubMed  Google Scholar 

  9. Jen MH, Saxena S, Bottle A, Aylin P, Pollok RC. Increased health burden associated with Clostridium difficile diarrhoea in patients with inflammatory bowel disease. Aliment Pharmacol Ther. 2011;33(12):1322–31.

    Article  CAS  PubMed  Google Scholar 

  10. Murthy S, Steinhart AH, Tinmouth J, Austin PC, Daneman N, Nguyen GC. Impact of Clostridium difficile colitis on 5-year health outcomes in patients with ulcerative colitis. Aliment Pharmacol Ther. 2012;36(11–12):1032–9.

    Article  CAS  PubMed  Google Scholar 

  11. Ananthakrishnan AN, Guzman-Perez R, Gainer V, et al. Predictors of severe outcomes associated with Clostridium difficile infection in patients with inflammatory bowel disease. Aliment Pharmacol Ther. 2012;35(7):789–95.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Surawicz CM, Brandt LJ, Binion DG, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108(4):478–98.

    Article  CAS  PubMed  Google Scholar 

  13. 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(5):1162–9.

    Article  PubMed  Google Scholar 

  14. Shen BO, Jiang ZD, Fazio VW, et al. Clostridium difficile infection in patients with ileal pouch-anal anastomosis. Clin Gastroenterol Hepatol. 2008;6(7):782–8.

    Article  CAS  PubMed  Google Scholar 

  15. Li Y, Qian J, Queener E, Shen B. Risk factors and outcome of PCR-detected Clostridium difficile infection in ileal pouch patients. Inflamm Bowel Dis. 2013;19(2):397–403.

    Article  PubMed  Google Scholar 

  16. Dineen SP, Bailey SH, Pham TH, Huerta S. Clostridium difficile enteritis: a report of two cases and systematic literature review. World J Gastrointest Surg. 2013;5(3):37–42.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Goodhand JR, Alazawi W, Rampton DS. Systematic review: clostridium difficile and inflammatory bowel disease. Aliment Pharmacol Ther. 2011;33(4):428–41. Article serves as a concise analysis on C. difficile and IBD.

  18. Ben-Horin S, Margalit M, Bossuyt P, et al. Prevalence and clinical impact of endoscopic pseudomembranes in patients with inflammatory bowel disease and Clostridium difficile infection. J Crohns Colitis. 2010;4(2):194–8.

    Article  PubMed  Google Scholar 

  19. Bossuyt P, Verhaegen J, Van Assche G, Rutgeerts P, Vermeire S. Increasing incidence of Clostridium difficile-associated diarrhea in inflammatory bowel disease. J Crohns Colitis. 2009;3(1):4–7.

    Article  PubMed  Google Scholar 

  20. Schneeweiss S, Korzenik J, Solomon DH, Canning C, Lee J, Bressler B. Infliximab and other immunomodulating drugs in patients with inflammatory bowel disease and the risk of serious bacterial infections. Aliment Pharmacol Ther. 2009;30(3):253–64.

    Article  CAS  PubMed  Google Scholar 

  21. Das R, Feuerstadt P, Brandt LJ. Glucocorticoids are associated with increased risk of short-term mortality in hospitalized patients with Clostridium difficile-associated disease. Am J Gastroenterol. 2010;105:2040–9.

    Article  CAS  PubMed  Google Scholar 

  22. Ben-Horin S, Margalit M, Bossuyt P, et al. Combination immunomodulator and antibiotic treatment in patients with inflammatory bowel disease and Clostridium difficile infection. Clin Gastroenterol Hepatol. 2009;7:981–7.

    Article  PubMed  Google Scholar 

  23. Bien J, Palagani V, Bozko P. The intestinal microbiota dysbiosis and Clostridium difficile infection: is there a relationship with inflammatory bowel disease? Therap Adv Gastroenterol. 2013;6(1):53–68. Excellent review on C. difficile, IBD and dysbiosis.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Monaghan TM, Cockayne A, Mahida YR. Pathogenesis of Clostridium difficile infection and its potential role in inflammatory bowel disease. Inflamm Bowel Dis. 2015;21(8):1957–66.

    Article  PubMed  Google Scholar 

  25. Brandt LJ. American journal of gastroenterology lecture: intestinal microbiota and the role of fecal microbiota transplant (FMT) in treatment of C. Difficile infection. Am J Gastroenterol. 2013;108(2):177–85.

    Article  PubMed  Google Scholar 

  26. Sheehan D, Moran C, Shanahan F. The microbiota in inflammatory bowel disease. J Gastroenterol. 2015;50(5):495–507.

    Article  CAS  PubMed  Google Scholar 

  27. Rajilić-Stojanović M, Shanahan F, Guarner F, de Vos WM. Phylogenetic analysis of dysbiosis in ulcerative colitis during remission. Inflamm Bowel Dis. 2013;19(3):481–8.

    Article  PubMed  Google Scholar 

  28. Gevers D, Kugathasan S, Denson LA, et al. The treatment-naive microbiome in new-onset Crohn’s disease. Cell Host Microbe. 2014;15(3):382–92.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Buffie CG, Bucci V, Stein RR, et al. Precision microbiome reconstitution restores bile acid mediated resistance to Clostridium difficile. Nature. 2015;517(7533):205–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Sorg JA, Sonenshein AL. Bile salts and glycine as cogerminants for Clostridium difficile spores. J Bacteriol. 2008;190(7):2505–12.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Ridlon JM, Kang DJ, Hylemon PB. Bile salt biotransformations by human intestinal bacteria. J Lipid Res. 2006;47(2):241–59.

    Article  CAS  PubMed  Google Scholar 

  32. Sorg JA, Sonenshein AL. Chenodeoxycholate is an inhibitor of Clostridium difficile spore germination. J Bacteriol. 2009;191(3):1115–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Vítek L. Bile acid malabsorption in inflammatory bowel disease. Inflamm Bowel Dis. 2015;21(2):476–83.

    Article  PubMed  Google Scholar 

  34. Kyne L, Warny M, Qamar A, Kelly CP. Asymptomatic carriage of Clostridium difficile and serum levels of IgG antibody against toxin A. N Engl J Med. 2000;342(6):390–7.

    Article  CAS  PubMed  Google Scholar 

  35. Monaghan TM, Robins A, Knox A, Sewell HF, Mahida YR. Circulating antibody and memory B-Cell responses to C. difficile toxins A and B in patients with C. difficile-associated diarrhoea, inflammatory bowel disease and cystic fibrosis. PLoS One. 2013;8(9):e74452.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Kyne L, Warny M, Qamar A, Kelly CP. Association between antibody response to toxin A and protection against recurrent Clostridium difficile diarrhoea. Lancet. 2001;357(9251):189–93.

    Article  CAS  PubMed  Google Scholar 

  37. Bauer MP, Nibbering PH, Poxton IR, Kuijper EJ, van Dissel JT. Humoral immune response as predictor of recurrence in Clostridium difficile infection. Clin Microbiol Infect. 2014;20(12):1323–8.

    Article  CAS  PubMed  Google Scholar 

  38. Johal SS, Lambert CP, Hammond J, James PD, Borriello SP, Mahida YR. Colonic IgA producing cells and macrophages are reduced in recurrent and non-recurrent Clostridium difficile associated diarrhoea. J Clin Pathol. 2004;57(9):973–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. Islam J, Taylor AL, Rao K, et al. The role of the humoral immune response to Clostridium difficile toxins A and B in susceptibility to C. difficile infection: a case-control study. Anaerobe. 2014;27:82–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Shakir FA, Ali T, Bigham AC, Ballard JD, Miner Jr PB, Philpott JR. Determination of serum antibodies to Clostridium difficile toxin B in patients with inflammatory bowel disease. Gastroenterol Hepatol (N Y). 2012;8(5):313–7.

    Google Scholar 

  41. Hourigan SK, Chirumamilla SR, Ross T, et al. Clostridium difficile carriage and serum antitoxin responses in children with inflammatory bowel disease. Inflamm Bowel Dis. 2013;19(13):2744–52.

    Article  PubMed  Google Scholar 

  42. Rai T, Wu X, Shen B. Frequency and risk factors of low immunoglobulin levels in patients with inflammatory bowel disease. Gastroenterol Rep (Oxf). 2015;3(2):115–21.

    Article  Google Scholar 

  43. Mokry M, Middendorp S, Wiegerinck CL, et al. Many inflammatory bowel disease risk loci include regions that regulate gene expression in immune cells and the intestinal epithelium. Gastroenterology. 2014;146(4):1040–7.

    Article  CAS  PubMed  Google Scholar 

  44. Ananthakrishnan AN, Oxford EC, Nguyen DD, Sauk J, Yajnik V, Xavier RJ. Genetic risk factors for Clostridium difficile infection in ulcerative colitis. Aliment Pharmacol Ther. 2013;38(5):522–30.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Bagdasarian N, Rao K, Malani PN. Diagnosis and treatment of Clostridium difficile in adults: a systematic review. JAMA. 2015;313:398–408. Contains important information on C. difficile diagnosis.

  46. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31:431–55.

    Article  PubMed  Google Scholar 

  47. Wilcox MH. Overcoming barriers to effective recognition and diagnosis of Clostridium difficile infection. Clin Microbiol Infect. 2012;18 Suppl 6:13–20.

    Article  PubMed  Google Scholar 

  48. Crobach MJ, Dekkers OM, Wilcox MH, Kuijper EJ. European Society of Clinical Microbiology and Infectious Diseases (ESCMID): data review and recommendations for diagnosing Clostridium difficile-infection (CDI). Clin Microbiol Infect. 2009;15:1053–66.

    Article  CAS  PubMed  Google Scholar 

  49. Shetty N, Wren MW, Coen PG. The role of glutamate dehydrogenase for the detection of Clostridium difficile in faecal samples: a meta-analysis. J Hosp Infect. 2011;77:1–6.

    Article  CAS  PubMed  Google Scholar 

  50. Shim JK, Johnson S, Samore MH, Bliss DZ, Gerding DN. Primary symptomless colonisation by Clostridium difficile and decreased risk of subsequent diarrhoea. Lancet. 1998;351:633–6.

    Article  CAS  PubMed  Google Scholar 

  51. Planche T, Aghaizu A, Holliman R, et al. Diagnosis of Clostridium difficile infection by toxin detection kits: a systematic review. Lancet Infect Dis. 2008;8:777–84.

    Article  PubMed  Google Scholar 

  52. Deshpande A, Pasupuleti V, Rolston DD, et al. Diagnostic accuracy of real-time polymerase chain reaction in detection of Clostridium difficile in the stool samples of patients with suspected Clostridium difficile infection: a meta-analysis. Clin Infect Dis. 2011;53:e81–90.

    Article  PubMed  Google Scholar 

  53. O’Horo JC, Jones A, Sternke M, Harper C, Safdar N. Molecular techniques for diagnosis of Clostridium difficile infection: systematic review and meta-analysis. Mayo Clin Proc. 2012;87:643–51.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Gilligan PH. Optimizing the laboratory diagnosis of Clostridium difficile infection. Clin Lab Med. 2015;35:299–312.

    Article  PubMed  Google Scholar 

  55. Debast SB, Bauer MP, Kuijper EJ. European society of clinical microbiology and infectious diseases: update of the treatment guidance document for Clostridium difficile infection. Clin Microbiol Infect. 2014;20 Suppl 2:1–26.

    Article  CAS  PubMed  Google Scholar 

  56. Planche TD, Davies KA, Coen PG, et al. Differences in outcome according to Clostridium difficile testing method: a prospective multicentre diagnostic validation study of C. difficile infection. Lancet Infect Dis. 2013;13:936–45.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Nelson RL, Kelsey P, Leeman H, et al. Antibiotic treatment for Clostridium difficile-associated diarrhea in adults. Cochrane Database Syst Rev. 2011;9, CD004610.

    PubMed  Google Scholar 

  58. Musher DM, Aslam S, Logan N, et al. Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis. 2005;40(11):1586–90.

    Article  CAS  PubMed  Google Scholar 

  59. Johnson S, Louie TJ, Gerding DN, et al. Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: results from two multinational, randomized, controlled trials. Clin Infect Dis. 2014;59(3):345–54.

    Article  CAS  PubMed  Google Scholar 

  60. Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45(3):302–7. Explains CDI treatment stratified by disease severity.

    Article  CAS  PubMed  Google Scholar 

  61. Horton HA, Dezfoli S, Berel D, et al. Antibiotics for treatment of clostridium difficile infection in hospitalized patients with inflammatory bowel disease. Antimicrob Agents Chemother. 2014;58(9):5054–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  62. Mezoff E, Mann EA, Hart KW, Lindsell CJ, Cohen MB. Clostridium difficile infection and treatment in the pediatric inflammatory bowel disease population. J Pediatr Gastroenterol Nutr. 2011;52(4):437–41.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Louie TJ, Miller MA, Mullane KM, et al. Fidaxomicin versus vancomycin for Clostridium difficile infection. N Engl J Med. 2011;364(5):422–31.

    Article  CAS  PubMed  Google Scholar 

  64. Cornely OA, Crook DW, Esposito R, et al. Fidaxomicin versus vancomycin for infection with Clostridium difficile in Europe, Canada, and the USA: a double-blind, non-inferiority, randomised controlled trial. Lancet Infect Dis. 2012;12(4):281–9.

    Article  CAS  PubMed  Google Scholar 

  65. Clutter DS, Dubrovskaya Y, Merl MY, Teperman L, Press R, Safdar A. Fidaxomicin versus conventional antimicrobial therapy in 59 recipients of solid organ and hematopoietic stem cell transplantation with Clostridium difficile-associated diarrhea. Antimicrob Agents Chemother. 2013;57(9):4501–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  66. van Nood E, Vrieze A, Nieuwdorp M, et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med. 2013;368(5):407–15.

    Article  PubMed  Google Scholar 

  67. Sha S, Liang J, Chen M, et al. Systematic review: faecal microbiota transplantation therapy for digestive and nondigestive disorders in adults and children. Aliment Pharmacol Ther. 2014;39(10):1003–32.

    Article  CAS  PubMed  Google Scholar 

  68. Hamilton MJ, Weingarden AR, Sadowsky MJ, Khoruts A. Standardized frozen preparation for transplantation of fecal microbiota for recurrent Clostridium difficile infection. Am J Gastroenterol. 2012;107(5):761–7.

    Article  PubMed  Google Scholar 

  69. Kelly CR, Ihunnah C, Fischer M, et al. Fecal microbiota transplant for treatment of Clostridium difficile infection in immunocompromised patients. Am J Gastroenterol. 2014;109(7):1065–71. Article discusses fecal transplant in immunocompromised patients.

    Article  PubMed  Google Scholar 

  70. Lowy I, Molrine DC, Leav BA, et al. Treatment with monoclonal antibodies against Clostridium difficile toxins. N Engl J Med. 2010;362(3):197–205.

    Article  CAS  PubMed  Google Scholar 

  71. Howerton A, Patra M, Abel-Santos E. A new strategy for the prevention of Clostridium difficile infection. J Infect Dis. 2013;207(10):1498–504.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Nancy Fu.

Ethics declarations

Conflict of Interest

Dr. Fu and Dr. Wong report no conflicts of interests.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by the author.

Additional information

This article is part of the Topical Collection on Intra-abdominal Infections, Hepatitis, and Gastroenteritis

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Fu, N., Wong, T. Clostridium difficile Infection in Patients with Inflammatory Bowel Disease. Curr Infect Dis Rep 18, 19 (2016). https://doi.org/10.1007/s11908-016-0525-x

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11908-016-0525-x

Keywords

Navigation