Anti-TNF containing regimens may be associated with increased risk of Clostridioides difficile infection in patients with underlying inflammatory bowel disease - 13/05/20

Doi : 10.1016/j.retram.2020.03.002

Fahimeh Sadat Gholam-Mostafaei ^a, Abbas Yadegar ^b,⁎ , Hamid Asadzadeh Aghdaei ^a, Masoumeh Azimirad ^b, Nasser Ebrahimi Daryani ^c, Mohammad Reza Zali ^d
^a Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
^b Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
^c Department of Gastroenterology and Hepatology, Tehran University of Medical Sciences, Tehran, Iran
^d Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran

^⁎Corresponding author at: Foodborne and Waterborne Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Shahid Arabi Ave., Yemen St., Velenjak, Tehran, Iran.Foodborne and Waterborne Diseases Research CenterResearch Institute for Gastroenterology and Liver DiseasesShahid Beheshti University of Medical SciencesShahid Arabi Ave.Yemen St.VelenjakTehranIran

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Highlights

•	Considerable incidence of CDI in a group of Iranian patients with IBD.
•	High prevalence of toxigenic C. difficile isolates among patients with IBD.
•	Potential risk of anti-TNF containing regimens and emergence of CDI.

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Abstract

Background

Patients with inflammatory bowel disease (IBD) are at greater risk for Clostridioides difficile infection (CDI). There remain controversial issues about the association of infliximab therapy in IBD patients and CDI.

Objective

The present work aimed to investigate the potential association between infliximab therapy and the risk of CDI in a group of Iranian patients with IBD.

Patients and methods

A total of 140 IBD patients were enrolled, their fresh stool specimens were obtained and used for C. difficile detection. The presence of toxin-encoding genes of C. difficile isolates were examined by PCR. Demographic data, frequency of defecation, antibiotic usage, and IBD therapy were recorded.

Results

About half of the IBD patients had a history of antibiotic usage, mostly metronidazole (11.4 %) alone, and metronidazole + ciprofloxacin (16.4 %) as drug combination. C. difficile was isolated from 17.1 % (24/140) of the IBD patients, and more than 90 % of the isolates were found to be toxigenic having genotypes of tcdA⁺/tcdB⁺ (18/22, 81.8 %), tcdA⁺/tcdB⁻ (3/22, 13.6 %) and tcdA⁻/tcdB⁺ (1/22, 4.5 %). Interestingly, we only found a significant relationship between the emergence of CDI and the use of infliximab in combinations with other drugs (P = 0.023).

Conclusions

In conclusion, there was a considerable incidence of CDI in Iranian patients with IBD. Our study also demonstrated that anti-TNF containing regimens in combinations with other immunosuppressive medications potentially may influence susceptibility to CDI in a group of patients with underlying IBD. Furthermore, our findings recommend avoiding the prolonged use of infliximab along with other corticosteroids or immunomodulators. Further validation studies are needed to better understand the mechanisms that regulate TNF-mediated pathways in CDI pathogenesis among IBD patients.

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Keywords : Clostridioides difficile infection, Inflammatory bowel disease, Anti-TNF therapy, Infliximab, Immunosuppressive drugs