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P739 Infections with C. difficile in inflammatory bowel disease patients are difficult to treat and frequently recur

E. Gombotz*1, E. Leitner2, I. Zollner-Schwetz3, R. Krause3, C. Kornschober4, H. Wenzl1, P. Kump1, W. Petritsch1, C. Högenauer1

1Medical University of Graz, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Graz, Austria, 2Medical University of Graz, Institute of Hygiene, Microbiology and Environmental Medicine, Graz, Austria, 3Medical University of Graz, Department of Internal Medicine, Section of Infectious Diseases and Tropical Medicine, Graz, Austria, 4Austrian Agency for Health and Food Safety, Graz, Austria

Background

As compared with findings in the general population, Clostridium difficile is detected more often in patients with inflammatory bowel disease (IBD). However, the relevance and outcome of this infection (CDI) with regard to disease activity and symptoms remain unclear. Our aims were to study the presence of risk factors for CDI in IBD, the effect of treatment with specific antibiotics directed against C. difficile on symptoms, the occurrence of recurrent CDI and associated risk factors, and the long-term outcome of IBD patients with C. difficile infections.

Methods

IBD patients tested positive for toxin-producing C. difficile between 2006 and 2014 from the University Hospital in Graz, Austria, were included in this retrospective study. Relevant demographic information, established risk factors for CDI (previous antibiotic therapy, PPI therapy, and hospitalisation) and treatment details were retrieved from patient records. The Fisher’s exact test was used to determine statistical significance.

Results

In total, 60 patients (25 CD; 35 UC) were tested positive for toxin-producing C. difficile 93 times. From 25 CD patients, 21 (84%) had colonic disease, and from 35 UC patients, 28 (80%) had extended colitis (Montréal E3). Further, 23 patients (38%) experienced more than one (2–5) CDI episode. Patients with recurrent CDI were significantly more often affected by CDI risk factors at the time of the first infection compared with patients with only one CDI episode (16/23 [70%] vs 15/37 [41%], p = 0.036). There was a non-significant trend for difference in immunosuppressive therapy between patients with recurrent CDI compared with patients with only one CDI episode (18/23 [78%] vs 20/37 [54%], p = 0.097). In 37 of 93 (40%), infectious episodes antibiotics directed against C. difficile improved the condition of the patient; in 19 of 93 (20%) episodes, no improvement was recordable or the patient was in remission. In the remaining 37 of 93 (40%) CDIs, it was impossible to determine the effect of antibiotics mainly because of concomitant initiation of immunosuppressive medication. Within the first year after the initial infection, 17% required a new therapy with azathioprine/6-mercatopurine/methotrexate; 7% with calcineurin inhibitors; and 22% with TNF-α-blockers. Surgery was required in 13% of patients.

Conclusion

Our results indicate that C. difficile infections in IBD patients are difficult to treat and frequently recur. Recurrent disease is significantly associated with risk factors for CDI. Antibiotics directed against C. difficile only partially improve the disease activity. Prospective studies to identify patients who benefit from an antibiotic therapy are urgently warranted.