Original article—alimentary tract
Clostridium difficile Infection in Patients With Ileal Pouch–Anal Anastomosis

https://doi.org/10.1016/j.cgh.2008.02.021Get rights and content

Background & Aims: There has been an increase in the incidence and severity of Clostridium difficile–associated diarrhea in the U.S. The importance of C difficile infection in patients with ileal pouch–anal anastomosis (IPAA) is unknown. This study was designed to determine risk of acquiring C difficile infection in pouch disorders. Methods: Consecutive ulcerative colitis patients (n = 115) with IPAA undergoing pouch endoscopy were enrolled from May 2005–March 2006. Fecal specimens of pouch aspirate were collected during pouch endoscopy and analyzed for C difficile toxin A and B by enzyme-linked immunosorbent assay. Nineteen clinical, endoscopic, and histologic variables were assessed with stepwise selection methods. Two multivariate logistic regression models were constructed. Results: Twenty-one patients (18.3%) were positive for C difficile infection. Adjusting for other factors in the model, men were 5.12 (95% confidence interval, 1.38–20.46) times more likely to have C difficile infection than women. Compared with patients with pancolitis, those with preoperative left-sided colitis were 8.4 (95% confidence interval, 1.25–56.4) times more likely to have C difficile infection. Six of 6 patients with C difficile infection (3 with refractory pouchitis, 2 with Crohn's disease, and 1 with irritable pouch syndrome) with repeat clinical, endoscopic, and laboratory evaluation after anti–C difficile therapy experienced clinical remission and disappearance of C difficile toxin from stools, with 4 showing decreased mucosal inflammation. Conclusions:C difficile infection involving IPAA is common, characteristically occurring with or without previous receipt of antibiotics. Treatment of C difficile infection in patients with IPAA might improve the clinical outcome.

Section snippets

Patients

The Cleveland Clinic Institutional Review Board approved this study, and informed consent was obtained from all patients. From our Pouchitis Clinic from May 2005–March 2006, we enrolled 115 consecutive IPAA patients with underlying UC who underwent routine diagnostic or surveillance pouch endoscopy. To minimize selection bias, we conducted the study on all consecutive patients who met inclusion criteria.

Inclusion and Exclusion Criteria

Inclusion criteria were IPAA patients (1) with underlying UC and (2) undergoing diagnostic

Results

Non–C difficile enteric pathogens were not detected in pouch aspirates. Of 115 patients with UC who had IPAA, 21 (18.3%) tested positive for C difficile toxin. On the basis of a univariable analysis (Table 1, Table 2, Table 3), only gender was significantly associated with having CDI (P = .024). Compared with women, men were 3.58 (95% confidence interval, 1.12–11.46) times more likely to have CDI. No other factors were found to be significantly associated with CDI. Specifically, stage of IPAA,

Discussion

The prevalence and incidence of CDI have appeared to be increasing in recent years, particularly in institutionalized patients.22, 23, 24 In addition, recent studies have also shown that concurrent CDI is prevalent in patients with IBD.15, 25 Purported risk factors for C difficile-associated colitis or diarrhea are maintenance immunomodulator use,15 colonic involvement of IBD, and a diagnosis of UC.25

In IBD, CDI might be associated with disease activation and refractoriness.26 Whether the

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    Dr DuPont has received honoraria for speaking for the following companies: Salix Pharmaceuticals, Merck Vaccine Division, McNeil Consumer Healthcare, Romark Institute for Medical Research, Merck Vaccine Division, and IOMAI Corporation and has received grants through the University of Texas to support research from Salix Pharmaceuticals, Romark Institute for Medical Research, IOMAI Corporation, and Optimer Pharmaceuticals. Dr Shen has received honoraria and research grants from Salix Pharmaceuticals. Dr Jiang has received honoraria for speaking for Salix Pharmaceuticals and has received grants through the University of Texas to support research from Salix Pharmaceuticals.

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