P-048 YI Initial Treatment Decisions and Outcomes in Patients With Inflammatory Bowel Disease and Clostridium Difficile Infection

Abstract

BACKGROUND: Clostridium difficile has become an increasingly recognized enteric pathogen affecting patients with inflammatory bowel disease (IBD), with IBD established as an independent risk factor for development of C. difficile infection (CDI). CDI carries significant morbidity and mortality among patients with IBD; however, treatment algorithms and predictors of severe disease are not commonly recognized. We sought to characterize the effects of treatment decisions and baseline patient characteristics on outcomes of IBD patients with CDI at a single tertiary center. METHODS: Electronic database query was performed between the dates January 1, 2005 to June 30, 2011, for inpatient hospitalizations with a diagnosis of IBD (555.x for CD and 556.x for UC) and concomitant positive C. difficile assay. Included patients presented with symptomatic colitis. Retrospective chart review was performed for baseline patient characteristics and was included with variables extracted from the electronic medical record. The composite primary outcome of interest included death and/or abdominal surgery related to C. difficile within 90 days of positive assay. Secondary outcomes of interest included re-hospitalization, recurrence of disease and total length of hospital stay. Univariate and multivariate logistic regression was performed to assess for predictors of the primary and secondary outcomes. RESULTS: One hundred thirty-five patients accounting for 135 hospitalizations were included in the final analysis. The median age was 36 years (range 17-88). Fiftyseven (42%) had Crohn's disease and 76 (56%) had Ulcerative colitis. Vancomycin was the initial antibiotic administered in 29 (21%) cases and metronidazole in 93 (69%). The 90-day composite primary outcome occurred in 17 (13%) patients. On multivariate analysis, predictors of the composite primary outcome included albumin < 3.3 g/dL (OR 3.09, 95% CI 1.03-9.27) and systemic steroid use on admission (OR 9.51, 95% CI, 2.05-44.04). The significant predictors of recurrence of C. difficile included a diagnosis of Ulcerative colitis, escalation of immunosuppressant therapy on discharge and initial administration of vancomycin. CONCLUSIONS: Predictors of severe disease in patients with IBD and CDI include the use of systemic steroids on hospital admission and albumin <3.3 g/dL. Escalation of immunosuppressant therapy on hospital discharge predicts recurrence of C. difficile assay positivity. Further studies will be required to create evidence-based treatment algorithms in the presentation of IBD patients with CDI.