Clostridium difficile and inflammatory bowel disease: implications for current clinical practice

Clostridium difficile infection should always be included in the differential diagnosis of patients with refractory inflammatory bowel disease (IBD) symptoms, as it is well known to induce or mimic a flare of IBD. There is currently an alarming increase in the incidence of C. difficile infection in Europe and North America. Current epidemiologic data suggest that more virulent strains, such as C. difficile 027/NAP1/BI, are emerging. Testing for both C. difficile toxins A and B should be done, and often serial stool samples may be required, especially if the index of suspicion is high. Patients with IBD do not necessarily require a history of antibiotic use or hospitalization to acquire the infection and most do not have pseudomembranes on sigmoidoscopy. C. difficile infection is associated with longer hospital stays, increased mortality, and higher complication rates, including colectomy. Treatment with oral vancomycin is probably the drug of choice as one study suggests that patients had lower colectomy rates on this drug. Further work is required to clarify the best management strategies for C. difficile in IBD patients, and more effort is needed to halt the rising incidence of this infection, perhaps with adherence to safer antibiotic prescribing guidelines, hand washing, and cleaner hospital environments, which should reduce the risk of acquiring and spreading this preventable infection.