This article is more than 5 years old. Information may no longer be current.
Enteric infections might play an important role in IBD flares
Click Here to Manage Email Alerts
Non-Clostridium difficile enteric infections, such as norovirus and Escherichia coli, might have an influence on flares of inflammatory bowel disease, according to research published in the American Journal of Gastroenterology.
Jordan E. Axelrad, MD, MPH, of the Inflammatory Bowel Disease Center at NYU Langone Health, and colleagues wrote that these infections could be causing intestinal dysbiosis, often thought to be a key environmental factor in the pathogenesis and maintenance of IBD.
“Enteric infection may be the sole etiology for an exacerbation in symptoms, coexist as a complicating factor, or represent asymptomatic colonization,” they wrote. “As such, the clinical importance and diagnostic approach to differentiating non-C. difficile enteric infection from flare remain unknown.”
Axelrad and colleagues conducted a cross-sectional analysis of 9,403 patients who underwent 13,231 stool tests to determine the distribution of non-C. diff enteric infections in patients with IBD. They used a gastrointestinal pathogen polymerase chain reaction (PCR) panel during a diarrheal illness between 2015 and 2017 to test for their primary outcome, the presence of an infection.
The study comprised 277 patients with Crohn’s disease, 300 patients with ulcerative colitis and 8,826 patients without IBD.
Compared with patients without IBD, patients with IBD were less likely to test positive for an infection (CD = 18.1%; UC = 16.1%; no IBD = 26.6%; P < .001).
However, Axelrad and colleagues found that patients with CD had a higher prevalence of norovirus (P = .05) and Campylobacter (P = .043) than patients without IBD. While patients with UC had a lower prevalence of norovirus (P = .001), they had a higher prevalence of Campylobacter (P = .013), Plesiomonas (P = .049), and E. Coli (P = .004).
While assessing their secondary outcomes, investigators found that endoscopic or histologic testing might not help differentiate IBD flare from infection.
“Our results suggest that infectious and non-infectious flare may elicit similar clinical, endoscopic and histologic findings, and PCR stool testing may identify potential pathogens,” the researchers wrote. “Although broad PCR testing impacted IBD management, endoscopy and histology did not differentiate flare from infection. As such, PCR testing should be considered as a diagnostic step in patients with an apparent relapse of IBD.” – by Alex Young
Disclosures: The authors report no relevant financial disclosures.
Perspective
Back to Top
Madhusudan Grover, MBBS
Enteric infections are frequently associated with flares in inflammatory bowel disease and can also lead to development of post-infection irritable bowel syndrome (PI-IBS). The current study retrospectively examines over 9,000 patients who underwent stool pathogen PCR panel testing for a diarrheal illness. Nearly 300 patients had Crohn’s disease or ulcerative colitis each and the remaining were “non-IBD.” Sixteen percent to 18% of IBD patients, vs. 27% of non-IBD patients, had a positive test. Compared with non-IBD patients, Crohn’s disease patients had higher prevalence of norovirus and Campylobacter and lower prevalence of parasites. In UC patients, bacterial infections were more common and parasitic and viral infections less common than non-IBD patients. Viruses, especially Norovirus, were more commonly detected in Crohn’s compared with UC. An important observation was that endoscopic and histological findings of IBD patients were similar in those without or with positive stool panel. Long term outcomes of those with and without infection were similar. Although, sample sizes for these analyses were small.
Overall, this study reinforces clinical challenges faced in the setting of positive stool PCR, especially in patients with IBD but also more generally. With use of highly sensitive panels, overall positivity and positivity for multiple pathogens (27%-35% in current study) poses difficulties in decision making and distinguishing true infection from colonization. Mechanistically, these observations are interesting and may reflect an association between intestinal virome and Crohn’s disease exacerbation. More detailed profiling of intestinal microbiota and intestinal tissue using next generation sequencing may allow better characterization of true enteric infection, especially in the setting of concomitant IBD.
Click Here to Manage Email Alerts