Pediatric IBD Patients at a Higher Risk for C Difficile Infections

Wael El-Matary, MD

Pediatric inflammatory bowel disease (IBD) patients are at an elevated risk for developing Clostridioides difficile infections (CDI), which could lead to treatment escalation later in life.

A team, led by Wael El-Matary, MD, University of Manitoba, Department of Pediatric Gastroenterology, investigated the incidence and risk factors associated with CDI in pediatric patients with IBD in Manitoba, Canada.

The data was presented during the 16th Congress of European Crohn's and Colitis Organisation (ECCO).

Toxigenic C difficile, is an anaerobic gram-positive spore-forming opportunistic pathogen associated with profuse diarrhea and gastroenteritis associated mortality, particularly for pediatric patients with IBD.

The Population

In the longitudinal population-based cohort, the investigators examined data for all children and adolescences younger than 17 years old diagnosed with IBD in Manitoba between 2011-2019. There was a total of 261 patients with IBD in the study, 7.7% (n = 20) of which developed a C difficile infection with an incidence rate of 5.04 cases per 1000 person-years.

The median age at diagnosis was 12.96 years old.

The team confirmed C difficile infections based on the Triage C difficile immunoassay and polymerase chain reaction assay to detect the presence of toxigenic C difficile. They also used Fisher’s exact test to examine the relationship between categorical variables and Cox-regression models to estimate the risk of CDI development in IBD patients.

Incidence Rates

For ulcerative colitis patients, the incidence rate of CDI was 4.16 cases per 1000 person-years, while the incidence rate was 5.88 cases per 1000 person-years in Crohn’s disease patients (P = 0.46).

Overall, pediatric patients with CDI were at an increased risk of future exposure to systemic corticosteroids (HR, 4.30; 95% CI, 1.44-12.87) and anti-tumor necrosis factor (TNF) biologics (HR, 3.37; 95% CI, 1.13–10.09)when compared to individuals without CDI.

The overall recurrence rate of CDI in the pediatric IBD population was 25%.

“Our findings confirm that children with IBD are at a high risk of developing CDI, which may predict future escalation of IBD therapy,” the authors wrote.

FMT Data from ECCO

In another abstract presented during ECCO, researchers found fecal microbiota transplantation (FMT) was a viable option for IBD patients with a CDI co-infection.

Fecal Microbiota Transplantation is a relatively new treatment approach for refractory C difficile infections. For patients with inflammatory bowel disease there is an increased risk of co-infection with CDI than there is for the general population because of the use of immunosuppressive medications and the dysbiosis of the bacteria in the colon.

There was 186 FMT requests to treat 176 rCDI patients between March 2016 and August 2019, including 26 patients with rCDI and IBD. In addition, 129 individuals, including 14 who suffered IBD, were treated with 143 FMTs for CDI with a cure rate of 89.9% after a single FMT (n = 116).

However, FMT was not suitable for 12 of the 26 IBD patients because these patients had C difficile carriership rather than an active CDI infection.

Three patients suffered from rCDI with an active episode of IBD, while 1 patient developed a relapse of a CDI infection within 2 months (total cure rate 92%). The cure rate did not differ from CDI patients without IBD.

The study, “Clostridioides difficile infection in children with inflammatory bowel disease: A Canadian population-based study,” was published online by the European Crohn’s and Colitis Organisation.