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Clostridium difficile Infection Among Individuals With Inflammatory Bowel Disease.

1 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 Dear Editors: We read with interest the article by Singh et al evaluating the incidence, risk factors, and outcomes after Clostridium difficile infection (CDI) in a population-based cohort of patients with inflammatory bowel disease (IBD) and laboratory confirmation diagnoses of CDI. The authors found that CDI incidence is no longer increasing among individuals with IBD, and CDI is associated with a greater increase in mortality among individuals without IBD than with IBD. Because their findings are important to current practice, several questions deserve attention. First, the standard clinical tests for CDI changed in the course of this study. Initially, the methods used were immunoassays for CDI toxins antigen; subsequently, the study used a nucleic acid amplification test for the detection of C difficile DNA. A nucleic acid amplification test might prove to be a better test than immunoassays for the detection of C difficile toxins A and B, and it became apparent that positive stool testing failed to distinguish between an asymptomatic carrier state and true infection. This distinction is important, because up to 30% of hospitalized patients are colonized with C difficile without toxin production or disease. Therefore, the trend of the CDI incidence in IBD over the study time period (6 years) in this study might be an inaccurate estimate of the real disease. At the same time, the study does not provide the time at which CDI was detected. Hence, it is not known if infection was acquired before or after hospitalization. In the latter case, one might conclude that CDI was the result of longer duration of stay rather than the cause of it. In addition, it is not known how many times C difficile testing was performed in each case. Repeat testing increases the likelihood of a false-positive C difficile result, especially if the clinical suspicion for CDI is low. This may explain the higher rates of CDI in patients with colonic Crohn’s, because these patients tend to present with diarrhea, which likely prompts more testing for CDI. Second, the study provides valuable information on risk factors for CDI in patients with IBD, such as hospitalizations, infliximab, or adalimumab. However, some studies have found that CDI was more commonly community acquired than hospital acquired, with the majority of the hospitalized patients in these studies testing positive within 48 hours of admission. CDI was acquired in the outpatient setting in 63% to 79% of cases. This was true even after exclusion of all cases of recurrent CDI. Thus, CDI seems to be more often a cause of hospitalization rather than the result of it in this