Antibiotics and Probiotics in Inflammatory Bowel Disease: Why, When, and How

Cosimo Prantera; Maria Lia Scribano

Disclosures

Curr Opin Gastroenterol. 2009;25(4):329-333. 

In This Article

Clostridium Difficile Infection and Inflammatory Bowel Disease

The flip side of the coin in which antibiotics are concerned is that they can induce IBD relapse by Clostridium difficile-associated disease (CDAD). In recent years fluoroquinolones have emerged as prominently implicated in this infection and their generalized employment in Crohn's disease and pouchitis has alerted the gastroenterological community. In 2007 two retrospective studies analysed the connection between IBD and CDAD.[27,28] The first reported the admission, between 1998 and 2004, of all cases of CDAD in the IBD and non-IBD population.[27] CDAD incidence was higher in IBD than non-IBD patients. Moreover there was an overall increased incidence during the 7 years under examination. The second study, assessing the impact of CDAD on IBD patients followed in a US referral centre during the years 2004–2005, registered an increase of the infection in the IBD cohort from 1.8% in 2004 to 4.6% in 2005.[28] Colonic involvement and immunosuppressors were significantly associated with the development of CDAD. This study also reported that more than half the infections required hospitalization and in 20% of cases colectomy was needed.

A further US study analysed the morbidity and mortality of CDAD on IBD patients, utilizing the data from Nationwide Inpatients Sample.[29•] The study reported that in patients with associated IBD and CDAD there was a four times greater mortality and longer hospitalization than in patients with IBD or CDAD alone. An editorial comment pinpointed the study's limitations, that is lack of information on severity of the cases, particularly on its relationship with surgery and mortality.[30•]

In conclusion, clinicians in charge of IBD patients must be aware of this risky complication, which can present the symptoms characteristics of IBD flares. Some symptoms, however, must alert to the possibility of CDAD, especially if they are more severe than those reported in the patient's previous clinical history, and if the white blood cell count exceeds 20 000 with increased number of neutrophils. We must consider that 20–40% of all hospitalized patients are colonized with C. difficile and that only in a few of them is there a conversion from spore to vegetative forms with replication and toxin production.[31] IBD patients are frequently on immunosuppressors, are often hospitalized and can be taking antibiotics, such as cipro and metro. Most strains of C. difficile are resistant to fluoroquinolones and an increasing resistance to metro has recently been registered. This resistance could be more pronounced in strains harboured in IBD patients, due to their occasional use of metro.

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