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GI infectious agents more common in active C. difficile, ulcerative colitis
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WASHINGTON — Patients with active Clostridium difficile infection or ulcerative colitis had a higher rate of detectable gastrointestinal infectious agents than asymptomatic patients, according to a study presented at Digestive Disease Week 2018.
Peter D.R. Higgins, from the University of Michigan, and colleagues also found that among patients with inflammatory bowel disease who experienced acute flares, 47% had a detectable infectious agent in their stool. However, patients with infectious agents had less severe flares and often responded to supportive care without corticosteroids.
“We know, or at least we believe, that intestinal infections matter in IBD ... and that C. difficile infections have been associated with longer hospital length of stay and increased colectomy,” Higgins said in his presentation. “This raises the question: can other gastrointestinal infections worsen IBD?”
Higgins and colleagues collected stool samples from the following cohorts: active Crohn’s disease (n = 112), inactive CD (n = 53), active ulcerative colitis (n = 128), inactive UC (n =39), and healthy controls (n = 52).
Overall, 31.25% of the patients with IBD had an infectious agent detected in their stool sample, with the highest prevalence in patients with active CD (33.9%) and UC (28.9%) compared with inactive CD (3.8%), inactive UC (12.8%) and the healthy controls (13.4%). Additionally, acuity of presentation predicted positive tests for infectious agents (P = .0007).
The presence of infectious agents correlated significantly with current use of Entyvio (vedolizumab, Takeda Pharmaceuticals) with an odds ratio of 3.9 (95% CI, 1.7-9.2) and tacrolimus (OR = 31.6; 95% CI, 4-247.2), but not with the use of anti-TNF, Stelara (ustekinumab, Janssen) or thiopurines.
“It’s important to not delay IBD treatment, unless you’re pretty convinced you have an infection. When we dug deeper and looked at which infections matter, we did find some differences. Other bacteria were comparable to C. diff infections, but the difference was really in the viral infections,” Higgins said. “It’s important to point out that, in general, these folks did well in supportive care, they did not need specific therapy, and it was important to not delay IBD therapy in the instance of severe IBD flare because of the presence of viral infection.” – by Talitha Bennett
Reference:
Limsrivilai J, et al. Abstract 91. Presented at: Digestive Disease Week; June 2-5, 2018; Washington, D.C.
Disclosure: Higgins reports he received consulting fees from AbbVie, Arena Pharmaceuticals, Eli Lilly, Janssen, Lycera, PRIME Medical Education, Takeda and UCB; and served on advisory committees or review panels for Janssen. Please see the DDW faculty disclosure index for a list of all other authors’ relevant financial disclosures.
Perspective
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Stephen B. Hanauer, MD
The University of Michigan IBD group evaluated the risk for gastrointestinal infections identified using the BioFire FilmArray GI PCR panel, a stool test capable of detecting 22 enteropathogenic organisms in patients with active or quiescent ulcerative colitis and Crohn’s disease, as well as healthy controls to determine the prevalence and impact of detected infectious agents in IBD patients. While C. difficile was the most common pathogen identified, there were several other pathogenic bacteria and viruses detected, most often (50%) in IBD patients with an acute onset (<7 days) of symptoms. The prevalence of infectious agents was ninefold higher in active vs. inactive CD (P = .0001) and twofold higher in active vs inactive UC (P = .04).
Guidelines have always suggested exclusion of enteric pathogens in newly diagnosed IBD as well as for patients with recent flares. To my knowledge the sensitivity, specificity and predictive values of the PCR panel used by investigators has not been specifically evaluated in patients with IBD. The possible risk for enteric pathogens in patients treated with vedolizumab is intriguing, if confirmed, due to the gut-specific mechanism of action. Overall, the study does support a cost-effective screening for enteric pathogens, particularly in patients with an acute onset of symptoms.
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