Higher Rates of Clostridium Difficile in Celiac Disease Patients

Benjamin Lebwohl, MD, MS

Benjamin Lebwohl, MD, MS

Rates of Clostridium difficile (C. difficile) infection are about twice as high among patients with celiac disease than in control patients, according to a recent report.

Researchers from the Mailman School of Public Health at Columbia University retrospectively identified 28,339 celiac disease patients in order to determine the population’s incidence of C. difficile. The researchers included 141,588 controls in their study, and noted that neither the celiac disease group or the control group had a history of C. difficile. The patients were all a part of a national Swedish patient cohort. Celiac disease patients are also at an increased risk for infections like tuberculosis, influenza and pneumococcal pneumonia, the researchers added.

The researchers noted that because of the nature of celiac disease, patients are often at an increased exposure to the healthcare system, which could, in turn, increase the exposure and risk of C. difficile infection — leading the researchers to track the annual number of outpatient visits from Jan. 1, 2001 onward. The investigators also analyzed and tracked medication use as confounding or mediating the link between celiac and C. difficile.

Among the more than 28,000 celiac disease patients, there were 136 cases of C. difficile (0.48%); in the 141,000 control patients, there were 357 cases of C. difficile (0.25%), the researchers reported. The risk of C. difficile infection was its highest in the first 12 months after a celiac disease diagnosis, but was still elevated within the 1 to 5 year period following celiac diagnosis, compared to non-celiac controls.

“The main finding in this study was that C. difficile infection was about twice as likely to occur in people with celiac disease compared to the general population,” study author Benjamin Lebwohl, MD, MS, told MD Magazine. “This may be due to the fact that people diagnosed with celiac disease have more interactions with health care (and C. difficile is often acquired in the health care setting), but may also be due to what is increasingly recognized as a greater susceptibility to a number of infections in people with celiac disease.”

At least 1 proton pump inhibitor prescription (omeprazole, esomeprazole, pantoprazole, lansoprazole, or rabeprazole) was noted in 21% of the celiac disease patients and 14% of the control patients. After looking at antibiotic data, which was available for just half of the control patients with C. difficile, the researchers found that 66% of them had been prescribed an antecedent antibiotic. The celiac disease patients were less likely than controls to have take penicillins (and more likely to have taken quinolones), the differences were not statistically significant, they said.

“These findings underscore the need to be judicious about antibiotic use, since this is a common trigger of C. difficile infection; antibiotics should not be given for most upper respiratory infections, since these are primarily caused by viruses. The findings also illustrate that recurrent symptoms in people with celiac disease are not necessarily due to gluten exposure; C. difficile should be considered as a potential cause of recurrent diarrhea in patients with celiac disease.”

One contributing factor to the possible rise in C. difficile numbers versus controls is that celiac patients may be more likely to seek evaluation for diarrhea than healthy controls, the researchers said. Health care itself might be mediating the relationship between celiac and C. difficile, they wrote.

The report, titled “Risk of Clostridium difficile Infection in Patients With Celiac Disease: A Population-Based Study,” was published in The American Journal of Gastroenterology.