Medline ® Abstracts for References 92,93
of 'Clostridium difficile infection in adults: Clinical manifestations and diagnosis'
Systematic review: Clostridium difficile and inflammatory bowel disease.
Goodhand JR, Alazawi W, Rampton DS
Aliment Pharmacol Ther. 2011 Feb;33(4):428-41. Epub 2010 Dec 30.
BACKGROUND: There is increasing concern about the apparently rising incidence and worsening outcome of Clostridium difficile infection (CDI) associated with inflammatory bowel disease (IBD). We have systematically reviewed the literature to evaluate the incidence, risk factors, endoscopic features, treatment and outcome of CDI complicating IBD.
AIM: To systematically review: clostridium difficile&inflammatory bowel disease.
METHODS: Structured searches of Pubmed up to September 2010 for original, cross-sectional, cohort and case-controlled studies were undertaken.
RESULTS: Of 407 studies, 42 met the inclusion criteria: their heterogeneity precluded formal meta-analysis. CDI is commoner in active IBD, particularly ulcerative colitis, than in controls. Certainty about a temporal trend to its increasing incidence in IBD is compromised by possible detection bias and miscoding. Risk factors include immunosuppressants and antibiotics, the latter less commonly than in controls. Endoscopy rarely shows pseudomembranes and is unhelpful for diagnosing CDI in IBD. There are no controlled therapeutic trials of CDI in IBD. In large studies, outcome of CDI in hospitalised IBD patients appears worse than in controls.
CONCLUSIONS: The complication of IBD by Clostridium difficile infection has received increasing attention in the past decade, but whether its incidence is really increasing or its outcome worsening remains unproven. Therapeutic trials of Clostridium difficile infection in IBD are lacking and are needed urgently.
Blizard Institute of Cell and Molecular Science, Queen Mary's University, London, UK.
Impact of Clostridium difficile on inflammatory bowel disease.
Ananthakrishnan AN, Binion DG
Expert Rev Gastroenterol Hepatol. 2010 Oct;4(5):589-600.
Clostridium difficile infection (CDI) has been increasing in incidence among those with underlying inflammatory bowel disease (IBD) and is associated with substantial morbidity, the need for surgery and even mortality. The similar clinical presentation between CDI and a flare of underlying IBD makes prompt diagnosis essential to prevent deterioration which would accompany an escalation of immunosuppression in the absence of appropriate antibiotic therapy. Classical risk factors (antibiotic or healthcare exposure) or clinical findings (pseudomembranes) may not be found in many IBD patients with CDI and should not be considered essential for entertaining the diagnosis. Enzyme immunoassays detecting both toxins A and B remain the most widely used test for diagnosis and have acceptable sensitivity, but may require testing of multiple samples in select situations. Both vancomycin and metronidazole appear to be effective and treatment with oral vancomycin is preferred in those with severe disease, including those who require hospitalization. Appropriate infection control measures are essential to restrict patient-to-patient spread within healthcare environments and to prevent recurrences. Several novel therapies are currently under study, including new antibiotic agents and monoclonal antibodies targeted against the toxins. There is a need to broaden these studies to the IBD population. There is also the need to prospectively examine whether CDI has long-term disease-modifying consequences in those with underlying IBD.
Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA, USA.