Management of Clostridioides difficile infection in patients with inflammatory bowel disease

Abstract

Inflammatory bowel disease (IBD) is a common diarrheal illness with gastrointestinal and extraintestinal manifestations and complications. The most common infectious complication associated with IBD is Clostridioides difficile infection (CDI). Active IBD predisposes to CDI due to alterations in the gut microbiome. C. difficile is a toxin producing bacterium leading to worsening of underlying IBD, increasing the risk of IBD treatment failure and an increased risk of hospitalization and surgery. Since the symptoms of CDI overlap with those of an IBD flare; it is prudent to recognize that the diagnosis of CDI is challenging and diagnostic tests (nucleic-acid and toxin-based assays) should be interpreted in context of symptoms and test performance. First line treatments for management of CDI in IBD include vancomycin or fidaxomicin. Recurrence prevention strategies should be implemented to mitigate recurrent CDI risk. One needs to monitor IBD disease progression and manage immunosuppression. The risk of recurrent CDI after a primary infection is higher in IBD compared to non-IBD patients. Microbiota restoration therapies are effective to prevent recurrent CDI in IBD patients. This review summarizes the epidemiology, pathophysiology, diagnostic testing, outcomes and management of both CDI and IBD, in CDI complicating IBD.

Keywords: Biologics; Clostridium difficile; Immunosuppression; Inflammatory bowel disease; Steroids.

Fig. 1.

Differences in the pathogenesis of C. difficile infection in patients with and without inflammatory bowel disease (IBD). Reprinted from Khanna S, et al. Clin Gastroenterol Hepatol 2017;15:166-174, with permission from Elsevier [3].

Fig. 2.

A proposed management algorithm for Clostridioides difficile infection (CDI) in patients with inflammatory bowel disease (IBD). ^aSevere-complicated also known as fulminant CDI is defined by the intensive care unit admission, hypotension, ileus/megacolon, mental status changes, leukocyte count greater than 35,000/μL or less than 2,000/μL, or lactate level greater than 2.2 mmol/L. These features are absent in uncomplicated CDI. Reprinted from Khanna S, et al. Clin Gastroenterol Hepatol 2017;15:166-174, with permission from Elsevier [3].