Clostridium Difficile Infection in Patients Impact Suspected Cytomegalovirus Infection in Patients with Inflammatory Bowel Disease

Maria Kosmidou; Nicoletta T Karavasili; Maria Saridi; Alexandros Skamnelos; Athanasios Kavvadias; Anna Batistatou; Konstantina G Gartzonika; Stavroula Tsiara; Konstantinos H Katsanos; Dimitrios K Christodoulou

doi:10.5455/msm.2020.32.41-45

Clostridium Difficile Infection in Patients Impact Suspected Cytomegalovirus Infection in Patients with Inflammatory Bowel Disease

Mater Sociomed. 2020 Mar;32(1):41-45. doi: 10.5455/msm.2020.32.41-45.

Affiliations

¹ 1st Division of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece.
² Infection Control Committee, University Hospital of Ioannina, Ioannina, Greece.
³ General Hospital of Corinth. Scientific Department of Social and Educational Policy, University of Peloponnese, Corinth. Hellenic Open University, Corinth, Greece.
⁴ Division of Gastroenterology, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece.
⁵ Pathology Laboratory, Chair of Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece.
⁶ Microbiology Laboratory, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece.
⁷ 2nd Division of Internal Medicine, Chair of Infection Control Committee, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece.

Abstract

Introduction: Clostridium difficile infection (CDI) has been reported to be a cause of flare-ups in patients with inflammatory bowel disease (IBD). Cytomegalovirus (CMV) infection can cause severe disease and complications in immunocompromised patients in consequence of disease or therapy.

Aim: Our aim was to describe the prevalence and clinical outcomes of CDI with concomitant CMV infection in IBD patients hospitalized for flare-ups in association with the disease itself and medication used.

Methods: We prospectively identified consecutive patients referred for CDI management during 2015-2017. Stool samples were tested for Clostridium difficile toxin A and/or B and Glutamate Dehydrogenase in patients with clinical symptoms. CDI patients with IBD history were tested for anti-CMV IgG and IgM antibodies by chemiluminescent microparticle immunoassay and underwent histological analysis for CMV on colon biopsies. Data were collected for demographic characteristics, treatment and outcome.

Results: 125 patients with CDI were enrolled. Among these patients, 14 (11.2%) were diagnosed with IBD. The mean patient age of IBD patients was 52.5±15.4 years at diagnosis of CDI, 85.7% had UC, 14.3% CD, while the age of patients was shared. Eleven of the total of 14 patients (78.6%) tested positive for anti-CMV IgG. Of these, 3 patients (21.4%) exhibited high CMV IgG avidity, without detectable anti-CMV IgM and biopsy-proven CMV colitis. Of the 14 IBD patients with CDI, 8 patients (57.1%) were receiving anti-tumor necrosis factor (anti-TNF) therapy (21.4 % infliximab or golimumab, 7.1% vedolizumab or adalimumab) and 43.5% of patients were being treated with systemic corticosteroids. Four UC patients (28.6%) on steroids of the 14 CDI patients underwent a colectomy whereas none of the not on steroids patients underwent colectomy (p=0.25). Among them, 1 patient (7.1%) had recurrent CDI after 5 months from the first episode of CDI.These patients were treated with vancomycin, metronidazole and fidaxomicin. The mean age of patients that had a colectomy 65.5±9.32 (n=4) was higher than the mean age of those 47.30±14.49 (n=10) who improved (U_Mann-Whitney=6. p=0.04).

Conclusions: Immunosuppressive medications and older age are associated with increased risk of CDI and poor outcome. Although, CMV is a rare colonic pathogen in the immunocompetent patient, it should be included and screened when exacerbation of IBD occurs in patients receiving any type of immunosuppressive therapy.

Keywords: Clostridium difficile; anti-TNF; cytomegalovirus; immunosuppression; infectious complications; inflammatory bowel disease.

© 2020 Maria Kosmidou, Nicoletta T. Karavasili, Maria Saridi, Alexandros Skamnelos, Athanasios Kavvadias, Anna Batistatou, Konstantina G. Gartzonika, Stavroula Tsiara, Konstantinos H. Katsanos, Dimitrios K. Christodoulou.