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P112. The triggering role of Clostridium difficile infection in the relapse of IBD and the clinical utility of fecal calprotectin and matrix-metallo-proteinase-9 in case of Clostridium-induced relapse

A. Balint1, M. Szucs2, K. Farkas1, E. Urbán3, F. Nagy1, Z. Szepes1, T. Wittmann1, T. Molnár1, 1University of Szeged, First Department of Medicine, Szeged, Hungary, 2University of Szeged, Department of Medical Physics and Informatics, Szeged, Hungary, 3University of Szeged, Institute of Clinical Microbiology, Szeged, Hungary

Background

Although the exact etiology of inflammatory bowel disease (IBD; CD - Crohn's disease and UC - ulcerative colitis) is unknown; one hypothesis suggests that the inflammation results from altered or pathogenic microbiota in a genetically susceptible host. IBD is a chronic disorder characterized by periods of remissions and relapses. The aim of our prospective study was to assess the frequency of enteral infections in the relapse of IBD, and to evaluate the clinical utility of fecal calprotectin (FC) and fecal matrix-metalloproteinase-9 (MMP-9) in this difficult situation.

Methods

Outpatients with IBD who developed acute relapse were enrolled prospectively from September, 2012 to July, 2013. Data of patients and the clinical activity indices (Crohn's Disease Activity Index-CDAI and partial Mayo score) were assessed, stool cultures, blood and stool samples were obtained for the determination of serum biochemical (C-reactive protein-CRP etc.) factors, FC and fecal MMP-9. IBD patients in remission were selected as a control group.

Results

90 IBD patients with relapse were enrolled in our study (male/female: 44/46, mean age: 36.68 years; CD/UC: 38/51). 49 subjects in clinical remission were enrolled in the control group. The mean values of CRP, leukocytes, FC and MMP-9 were 23.52 mg/l, 10.05 G/l, 1292.46 µg/g and 11.77 ng/ml in the relapsed group and 6.54 mg/l, 7.06 G/l, 216.11 µg/g, 3.46 ng/ml in the control group. The clinical activity indices showed mild and moderate disease activity: the mean value of CDAI was 227.9, and pMayo score was 5.2 points. 56.6% of patients had positive microbiological results. Clostridium difficile A and B toxin positivity was verified in 91% of the cases. Statistical analysis showed significant difference between FC and MMP-9 values in patients with relapse and remission, but not in Clostridium difficile positive and negative cases. Our results revealed an association between previous antibiotic use and Clostridium difficile positivity (p = 0.03).

Conclusion

We suggest that the presence of Clostridium difficile is very frequent in flare-ups of IBD and it has an important role in the relapse, therefore the stool analysis is recommended in every relapse to optimize therapy. FC and MMP-9 has no diagnostic power to differentiate between infection-induced and natural relapse.