The similar clinical presentations and laboratory findings in relapse of IBD and enteric infection pose substantial barriers to diagnosis and treatment. Infection with a wide range of gastrointestinal pathogens has been reported in association with relapse of IBD, with Clostridium difficile considered the most concerning. The increasing availability of rapid, highly sensitive, and highly specific nucleic acid amplification tests have improved gastrointestinal pathogen diagnostics. The objective of this study was to investigate the incidence, etiology, predictors, and treatment of enteric infection in relapse of IBD.Methods:
The medical records of 165 patients from Columbia University Medical Center with IBD who underwent a total of 234 gastrointestinal pathogen panel PCR (BioFire FilmArray, Salt Lake City, Utah) and C. difficile PCR (Cepheid Xpert) stool tests during an exacerbation of IBD were reviewed. The gastrointestinal pathogen PCR panel detects 22 enteric targets including common bacteria, parasitic, and viral pathogens. Baseline characteristics, PCR outcomes, and medication exposures (including 5-ASAs, corticosteroids, immunomodulators, biologics, antibiotics, proton pump inhibitors) were collected. Baseline characteristics were compared with the Chi-square test and the T test where appropriate. Logistic regression analysis was used to identify predictors of enteric infection.Results:
Of 234 PCR tests ordered during relapse of IBD, 34 (14.5%) were positive for C.difficile and 29 (12.4%) were positive for other enteric pathogens, with E.coli species (18) as the most common. Other enteric species detected included Campylobacter (6), Rotavirus (3), Shigella (2), Norovirus (2), Vibro species (1), Salmonella (1), and Saprovirus (2). Between patients who tested positive for C.difficile, positive for other enteric pathogens, or negative for both, there were no differences in IBD subtype, gender, ethnicity, median duration of disease, previous IBD medication exposure, IBD medication exposure at testing, proton pump inhibitor use, or hospitalization requirement (P > 0.05). Although few patients were exposed to vedolizumab (14), it was not associated with an increased risk of enteric infection. Patients with a previous history of C.difficile (OR 2.6, P = 0.011) or previous exposure to antibiotics within 90 days prior to testing (OR 2.2, P = 0.049) were more likely to test positive for C.difficile. All patients with C.difficile were treated, with the majority (23, 67.6%) receiving PO vancomycin. Less than half of patients with other enteric pathogens were treated for their infection (13, 44.8%). Patients with C.difficile had a longer median length of hospital stay (8.5 d) compared to patients without the infection (5 d; P = 0.005). Patients who tested negative for enteric infections were more likely to have IBD medications added or up-titrated (OR 2.6, P = 0.031).Conclusions:
In this cohort, enteric infection was detected in 63 (26.9%) relapses of inflammatory bowel disease, with C.difficile the most frequent culprit followed by E.coli species. Exposure to medications for IBD was not associated with C.difficile or other enteric infections. Negative stool gastrointestinal pathogen and C.difficile PCR testing was associated with a change in IBD management. Broad enteric PCR testing should be considered during relapse of IBD as it predicted IBD management. Further study should explore specific enteric pathogens with IBD disease course and outcomes.