- Email: [email protected]
Clostridium difficile enteritis: A review and pooled analysis of the cases
Anaerobe 17 (2011) 52e55
Contents lists available at ScienceDirect
Anaerobe journal homepage: www.elsevier.com/locate/anaerobe
Clostridium difficile enteritis: A review and pooled analysis of the cases J.H. Kim a, R.R. Muder a, b, * a b
Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA Infectious Disease Section, VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 November 2010 Received in revised form 9 February 2011 Accepted 12 February 2011 Available online 18 February 2011
Introduction: Clostridium difficile is the most common cause of healthcare-associated infection diarrhea and usually restricted to infection of the colon. However, small bowel involvement of C. difficile infection has been reported. We performed a literature review and pooled analysis of the reported cases of C. difficile enteritis Method: A Pubmed literature database search and pooled analysis of the reported cases of C. difficile enteritis. Results: 56 cases of C. difficile enteritis have been reported from 1980 to 2010; 48 cases were published since 2001. Median age was 55 years. 27 patients (48.2%) were female. 29 patients (51.8%) had inflammatory bowel disease (IBD) e Crohn’s disease or ulcerative colitis and 20 patients (35.7%) had predisposing medical condition(s) that might lead to an immunoincompetent state. 33 patients (58.9%) had colectomy with ileostomy and 13 patients (23.2%) had other small and/or large bowel surgery. Thirty four patients (60.7%) received ICU management and 18 patients (32.1%) died. We categorized the patients into two groups, 38 survivors (67.9%) 18 non-survivors (32.1%). Significantly older age was noted in nonsurvivors. Median age was 48 years and 66 years, respectively for survivors and non-survivors, P < 0.001. There were more patients with predisposing medical condition(s) among non-survivors, (13/18, 72.2%) than among survivors (7/38, 18.4%), P < 0.001. Conclusions: C. difficile enteritis is still rare, however it seems to be increasingly reported in recent years. Surgically altered intestinal anatomies, advanced age, predisposing medical condition(s) that might lead to immunoincompetence appear to be at risk for developing C. difficile enteritis. Recognition of C. difficile infection not only in the colon but also in the small bowel may lead to improved outcomes. Published by Elsevier Ltd.
Keywords: Clostridium difficile Enteritis
1. Introduction Clostridium difficile is the most common cause of healthcareassociated infectious diarrhea [1]; it is usually restricted to infection of the colon [2]. However, in rare circumstances, small bowel involvement of C. difficile infection has been reported. A severe clinical course leading to significant morbidity and mortality rates has been demonstrated in this small subset of patients with C. difficile infection. In this article, we present a review and pooled analysis of the reported cases of C. difficile enteritis. 2. Method We searched PubMed using the terms “enteritis” and “clostridium difficile”, and resulting English language entries were reviewed individually. All publications reporting cases of C. difficile e * Corresponding author. Infectious Disease Section, VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240, USA. Tel.: þ1 412 360 6179; fax: þ1 412 360 6950. E-mail address: [email protected] (R.R. Muder). 1075-9964/$ e see front matter Published by Elsevier Ltd. doi:10.1016/j.anaerobe.2011.02.002
associated small bowel enteritis were included in this review and pooled analysis. In addition, the references of these case reports were reviewed to find additional reported cases. The following data were extracted and categorized into variables: demographics including age and sex, pre-existing gastrointestinal disease conditions including presence of inflammatory bowel disease (ulcerative colitis or Crohn’s disease), predisposing medical condition(s) that might lead to immunoincompetence (malignancy, solid organ transplant recipient, liver cirrhosis, end stage renal disease, HIV, and active tuberculosis on treatment), previous C. difficile infection, previous gastrointestinal surgery (colectomy with ileostomy, other small bowel and/or large bowel surgery, surgeries of pelvis, rectum, prostate, gallbladder), recent antibiotic use, hospitalization before the onset of C. difficile enteritis, medical and surgical treatment for C. difficile small bowel enteritis, intensive care unit (ICU) transfer, and death. 2.1. Statistical analysis of pooled data We summarized each of the selected studies by recording these categorized variables and conducted a descriptive analysis. Then
J.H. Kim, R.R. Muder / Anaerobe 17 (2011) 52e55
we compared patients who survived with those who died. Pooled data in this study were analyzed using two-sided ManneWhitney test or Fisher’s exact test. SPSS, version 15.0 was used for the analysis. P values of less than 0.05 were considered to indicate statistical significance. 3. Result The Pubmed literature search revealed total of 56 cases from 1980 to 2010; 48 cases were published since 2001 [3e32]. The diagnosis of C. difficile enteritis was based on the following; 1. Positive C. difficile toxin in stool or ileostomy output in patients who previously had had colectomy with ileostomy (23 cases). 2. Positive C. difficile toxin in increased ileostomy output in patients with formation of ileostomy postoperatively (3 cases). 3. Autopsy, surgical pathology, or biopsy showing histologic evidence of enteritis with positive C. difficile toxin and/or C. difficile isolated on culture (30 cases). Median age was 55 years with interquartile range (IQR) of 41e70 years. 27 patients (48.2%) were female. 29 patients (51.8%) had inflammatory bowel disease (IBD) e Crohn’s disease or ulcerative colitis and 20 patients (35.7%) had predisposing medical condition(s) that might lead to an immunoincompetent state. Only 10 patients (17.9%) were noted to have neither IBD nor predisposing medical condition(s). 33 patients (58.9%) had colectomy with ileostomy and 13 patients (23.2%) had other small and/or large bowel surgery. The majority had recent antibiotic therapy (50 patients, 89.3%). Thirty four patients (60.7%) received ICU management and 18 patients (32.1%) died. Median time between the onset of symptoms or diagnosis of C. difficile enteritis and death was 4 days with IQR 2e20 days. These are shown in Table 1. Several interesting features of 29 IBD patients were noted: median age was younger (44 years) with IQR of 31e54 years: the majority of IBD patients (24 patients, 82.8%) had colectomy with ileostomy: only a few patients (3 patients, 10.3%) had predisposing medical condition(s) other than IBD: the mortality in this group was lower than that of the whole group (3 patients, 10.3%). We categorized the patients into two groups, 38 survivors (67.9%) 18 non-survivors (32.1%) for further analysis. Significantly older age was noted in non-survivors. Median age was 48 years with IQR 34e60 years and 66 years with IQR 60e76 years, respectively for survivors and non-survivors, P < 0.001. The presence of IBD was significantly different in these two groups. More survivors (26/38, 68.4%) had IBD than those who died (3/18, 16.7%), P < 0.001. There were more patients with predisposing medical condition(s) among non-survivors, (13/18, 72.2%) than among survivors (7/38, 18.4%), P < 0.001. Although the majority of patients had previous gastrointestinal (GI) surgery, types of previous GI surgery was significantly different between these two groups. More survivors had colectomy with (27/38, 71.1%) than non-survivors (6/18, 33.3%), P ¼ 0.010. Non-survivors required significantly more ICU management (17/18, 94.4%) than did survivors 17 patients (17/38, 44.7%). No significant differences were found among other clinical variables between two groups. These are shown in Table 2. 4. Discussion C. difficile is usually considered to be a colonic pathogen and is a common cause of antibiotic-associated diarrhea and colitis. Although C. difficile enteritis is quite rare, it has been increasingly recognized recently. Until the year 2000, 8 reports with 8 cases had been published [3e14]. The literature reveals an increasing number of 22 reports with 48 cases since 2001 [15e32]. Of the 56 cases reported so far, a total of 18 deaths were recorded, resulting in an overall mortality figure of 32.1%.
53
Table 1 Characteristics of previously published cumulative cases of C. difficile enteritis. Total number of patients: 56 Age (median, IQR)
55 (41e70)
Sex Female (%) Male (%)
27 (48.2) 29 (51.8)
IBDa (%) Predisposing medical conditionb (%) IBD and/or predisposing medical condition (%) Previous GI surgery* Colectomy with ileostomy (%) Other small/large bowel surgery (%) Other surgery (no small/large bowel) (%) No known previous GI surgery (%)
29 (51.8) 20 (35.7) 46 (82.1) 33 13 5 5
(58.9) (23.2) (8.9) (8.9)
Past C. difficile infection No past C. difficile infection (%) Past C. difficile infection (%) Unknown (%)
7 (12.5) 11 (19.6) 38 (67.9)
Recent antibiotic use No recent antibiotic use (%) Recent antibiotic use (%) Unknown (%)
5 (8.9) 50 (89.3) 1 (1.8)
Recent hospitalization No recent hospitalization (%) Recent hospitalization (%) Unknown (%)
7 (12.5) 33 (58.9) 10 (17.9)
ICU transfer No ICU transfer (%) ICU transfer (%) Unknown (%)
12 (21.4) 34 (60.7) 10 (17.9)
Death No death (%) Death (%) Time to death (days), median (IQR)
38 (67.9) 18 (32.1) 4 (2e20)
*Previous GI surgery Colectomy with ileostomy; total or proctocolectomy with ileostomy. Other small/large bowel surgery; subtotal colectomy, hemicolectomy, other small and/or large bowel surgery. Other surgery (no small/large bowel); other surgeries including prostate, gallbladder, bladder, pelvic without previous small and/or large bowel surgery. a IBD; inflammatory bowel disease including either Ulcerative Colitis or Crohn’s disease. b Predisposing medical condition; condition(s) including malignancy, solid organ transplant recipient, liver cirrhosis, end stage renal disease, HIV, and active tuberculosis on treatment which might lead to immunoincompetence.
The pathophysiology of C. difficile small bowel enteritis is not completely understood. Its association with severe disease course and a recent increase in reported cases is still unclear. However, there appears to be several factors to consider. C. difficile has been shown to be in the jejunum; the small bowel may serve as a reservoir for C. difficile [33]. In a rabbit ileal loop model, C. difficile toxin A (TcdA) has been shown to generate severe inflammatory enteritis, pathologic findings similar to those in human C. difficile infection [34]. The majority of patients we reviewed (46 patients, 82.1%) had previous GI surgery including colectomy with ileostomy, other small and/or large bowel surgery. Changes such as colonization of the neoterminal ileum by colonictype bacterial flora [35] and phenotypic changes in the epithelium of pelvic ileoanal pouches [36] have been reported after colectomy. These factors may facilitate colonization of fecal flora with overgrowth of C. difficile in the small bowel. Also majority of patients (50 patients, 89.3%) had recent antibiotic use prior to the development of C. difficile small bowel enteritis, likely resulting in
54
J.H. Kim, R.R. Muder / Anaerobe 17 (2011) 52e55
Table 2 Comparison of survivors and non-survivors in previously published cumulative cases of C. difficile enteritis. Survivors Non-survivors P N ¼ 38/56, 67.9% N ¼ 18/56, 32.1% Age (median, IQR)
48 (34e60)
66 (60e76)
<0.001
Presence of IBD (%) Predisposing medical condition (%)
26 (68.4) 7 (18.4)
3 (16.7) 13 (72.2)
<0.001 <0.001
27 (71.1) 6 (15.8)
6 (33.3) 7 (38.9)
0.010 0.089
1 (2.6)
4 (22.2)
0.033
4 (10.5)
1 (5.6)
1.000
Past C. difficile infection No past C. difficile infection (%) 6 (15.8) Past C. difficile infection (%) 9 (23.7) Unknown (%) 23 (60.5)
1 (5.6) 2 (11.1) 15 (83.3)
0.409 0.473 0.128
Recent antibiotic use No recent antibiotic use (%) Recent antibiotic use (%) Unknown (%)
4 (10.5) 33 (86.8) 1 (2.6)
1 (5.6) 17 (94.4) 0 (0.0)
1.000 0.652 1.000
Recent hospitalization No recent hospitalization (%) Recent hospitalization (%) Unknown (%)
6 (15.8) 22 (57.9) 10 (26.3)
1 (5.6) 11 (61.1) 6 (33.3)
0.409 1.000 0.752
ICU transfer No ICU transfer (%) ICU transfer (%) Unknown (%)
12 (31.6) 17 (44.7) 9 (23.7)
0 (0.0) 17 (94.4) 1 (5.6)
0.006 <0.001 0.143
8 13 13 1
3 4 10 1
Previous GI surgery Colectomy with ileostomy (%) Other small/large bowel surgery (%) Other surgery (no small/large bowel) (%) No known previous GI surgery (%)
Medical treatment^ Metro (%) Vanco (%) Metro and vanco (%) Metro and vanco and rifampin (%) Unknown or no treatment (%) Other treatment (%) Surgical treatment No surgery (%) Surgery (%)
(21.1) (34.2) (34.2) (2.6)
(16.7) (22.2) (55.6) (5.6)
1.000 0.535 0.155 0.544
2 (5.3) 1 (2.6)
0 (0.0) 0 (0.0)
1.000 1.000
29 (76.3) 9 (23.7)
9 (50.0) 9 (50.0)
0.068
^Medical treatment: Metro; metronidazole, Vanco; vancomycin, Other treatment; streptomycin.
eradication of other endogenous bowel flora and facilitating the proliferation of C. difficile. Therefore, a similar process of mucosal damage and inflammation mediated by enterotoxin produced during the proliferation of C. difficile may occur in the small bowel. The rates and severity of C. difficile infection in hospitals in North America and Europe have increased since 2000, largely due to dissemination of an epidemic strain, BI/NAP1/027 characterized by higher C. difficile toxin A (TcdA) and toxin B (TcdB) production from deletion of the tcdC gene [37]. In a neonatal pig model, TcdA binding was much more intense in the the small intestine, and experimental gavage of pigs with TcdA generated more severe lesions in the small intestine [38]. Thus, an epidemic strain, BI/NAP1/027 may be able to colonize and affect the small intestine more easily than previous strain, as suggested in one report [22]. Given the fact that 21 out of 22 published reports of C. difficile enteritis since 2001 were from North America and Europe, patients could have been infected by the epidemic strain. Thus, current C. difficile infection epidemics with BI/NAP1/027 strain may be
responsible for increased number of the cases recently, although cultures and typing of the strain data were not available for analysis. C. difficile infection in IBD patients has been reported to be associated with a higher mortality than in infection among those admitted to hospital for treatment of IBD alone or C. difficile infection alone [39]. However, among our patients, those with IBD and colectomy with ileostomy were more likely to survive. IBD patients who had C. difficile enteritis were younger, less likely to have concomitant condition(s), and more likely to receive medical attention due to their surgically e corrected pre-existing IBD condition. Therefore, IBD patients might have more physiologic reserve to mount an immune response against C. difficile enteritis than patients with more advanced age and predisposing medical condition(s). Advanced age and severe underlying illness have been identified as risk factors with increased risk of C. difficile carriage and diarrhea [40]. Host immunoglobulin G responses against C. difficile toxin A have been shown to protect against symptomatic C. difficile disease [41]. The majority of reported patients (46 patients, 82.1%) had IBD or predisposing medical condition(s) that might lead to immunoincompetence. And there were significantly more advanced older age and presence of predisposing medical condition(s) in non-survivors group. Taken together, our results support the idea that decreased immune response from advanced age and severe underlying illness may play a critical role in C. difficile small bowel enteritis. Our study has limitations, however, mostly stemming from its small sample size and its retrospective nature. First, C. difficile enteritis is a rare entity, however, C. difficile enteritis could have been more frequent and only severe cases would have been diagnosed and reported. Thus, it might reflect a selection bias toward C. difficile enteritis cases. Second, because cultures and typing of the strain data from C. difficile enteritis were not available, it was not possible to assess if the BI/NAP1/027 strain was responsible for cases. Third, there were no data measuring immunological markers such as immunoglobulin G levels against C. difficile toxin A, making difficult to evaluate whether decreased immune response was indeed attributable to development of symptomatic C. difficile enteritis with increased mortality. Finally, follow up was not available for all patients who survived. To our knowledge, this is the first pooled analysis comparing survival group and death group in C. difficile enteritis with a review of the literature. In conclusion, C. difficile enteritis is still rare, however it seems to be increasingly reported in recent years along with epidemic C. difficile BI/NAP1/027 strain with high mortality rates. Patients with surgically altered intestinal anatomies, advanced age, IBD, and predisposing medical condition(s) that might lead to immunoincompetence appear to be at risk for developing C. difficile enteritis. Early recognition of C. difficile infection not only in the colon but also in the small bowel might play a substantial role in preventing potential morbidity and mortality in this cohort of patients. References [1] Gerding DN, Johnson S, Peterson LR, Mulligan ME, Silva Jr J. Clostridium difficile diarrhea and colitis. Infect Control Hos Epidemiol 1995;16:459e77. [2] Bartlett JG. Clostridium difficile: clinical considerations. Rev Infect Dis 1990;12(suppl. 2):S243e51. [3] LaMont JT, Trnka YM. Therapeutic implications of clostridium difficile toxin during relapse of chronic inflammatory bowel disease. Lancet 1980 Feb 23;1(8165):381e3. [4] Shortland JR, Spencer RC, Williams JL. Pseudomembranous colitis associated with changes in an ileal conduit. J Clin Pathol 1983 Oct;36(10):1184e7. [5] Yee Jr HF, Brown Jr RS, Ostroff JW. Fatal clostridium difficile enteritis after total abdominal colectomy. J Clin Gastroenterol 1996 Jan;22(1):45e7.
J.H. Kim, R.R. Muder / Anaerobe 17 (2011) 52e55 [6] Miller DL, Sedlack JD, Holt RW. Perforation complicating rifampin-associated pseudomembranous enteritis. Arch Surg 1989 Sep;124(9):1082. [7] Kuntz DP, Shortsleeve MJ, Kantrowitz PA, Gauvin GP. Clostridium difficile enteritis. A cause of intramural gas. Dig Dis Sci 1993 Oct;38(10):1942e4. [8] Tsutaoka B, Hansen J, Johnson D, Holodniy M. Antibiotic-associated pseudomembranous enteritis due to clostridium difficile. Clin Infect Dis 1994 Jun;18(6):982e4. [9] Kralovich KA, Sacksner J, Karmy-Jones RA, Eggenberger JC. Pseudomembranous colitis with associated fulminant ileitis in the defunctionalized limb of a jejunal-ileal bypass. Report of a case. Dis Colon Rectum 1997 May;40(5):622e4. [10] Vesoulis Z, Williams G, Matthews BP. Seudomembranous enteritis after proctocolectomy: report of a case. Dis Colon Rectum 2000 Apr;43(4):551e4. [11] Tjandra JJ, Street A, Thomas RJ, Gibson R, Eng P, Cade J. Fatal clostridium difficile infection of the small bowel after complex colorectal surgery. ANZ J Surg 2001 Aug;71(8):500e3. [12] Jacobs A, Barnard K, Fishel R, Gradon JD. Extracolonic manifestations of Clostridium difficile infections. Presentation of 2 cases and review of the literature. Medicine (Baltimore) 2001 Mar;80(2):88e101. [13] Freiler JF, Durning SJ, Ender PT. Clostridium difficile small bowel enteritis occurring after total colectomy. Clin Infect Dis 2001 Oct 15;33(8):1429e31. [14] Mann SD, Pitt J, Springall RG, Thillainayagam AV. Clostridium difficile infectionean unusual cause of refractory pouchitis: report of a case. Dis Colon Rectum 2003 Feb;46(2):267e70. [15] Hayetian FD, Read TE, Brozovich M, Garvin RP, Caushaj PF. Ileal perforation secondary to Clostridium difficile enteritis: report of 2 cases. Arch Surg 2006 Jan;141(1):97e9. [16] Lundeen SJ, Otterson MF, Binion DG, Carman ET, Peppard WJ. Clostridium difficile enteritis: an early postoperative complication in inflammatory bowel disease patients after colectomy. J Gastrointest Surg 2007 Feb;11(2):138e42. [17] Kim KA, Wry P, Hughes Jr E, Butcher J, Barbot D. Clostridium difficile smallbowel enteritis after total proctocolectomy: a rare but fatal, easily missed diagnosis. Report of a case. Dis Colon Rectum 2007 Jun;50(6):920e3. [18] Follmar KE, Condron SA, Turner II , Nathan JD, Ludwig KA. Treatment of metronidazole-refractory clostridium difficile enteritis with vancomycin. Surg Infect (Larchmt) 2008 Apr;9(2):195e200. [19] Wood MJ, Hyman N, Hebert JC, Blaszyk H. Catastrophic clostridium difficile enteritis in a pelvic pouch patient: report of a case. J Gastrointest Surg 2008 Feb;12(2):350e2. [20] Yafi FA, Selvasekar CR, Cima RR. Clostridium difficile enteritis following total colectomy. Tech Coloproctol 2008 Mar;12(1):73e4. [21] Wee B, Poels JA, McCafferty IJ, Taniere P, Olliff J. A description of CT features of clostridium difficile infection of the small bowel in four patients and a review of literature. Br J Radiol 2009 Nov;82(983):890e5. [22] Lavallée C, Laufer B, Pépin J, Mitchell A, Dubé S, Labbé AC. Fatal clostridium difficile enteritis caused by the BI/NAP1/027 strain: a case series of ileal C. difficile infections. Clin Microbiol Infect 2009 Dec;15(12):1093e9. [23] Causey MW, Spencer MP, Steele SR. Clostridium difficile enteritis after colectomy. Am Surg 2009 Dec;75(12):1203e6.
55
[24] Shen B, Remzi FH, Fazio VW. Fulminant clostridium difficile-associated pouchitis with a fatal outcome. Nat Rev Gastroenterol Hepatol 2009 Aug;6(8):492e5. [25] Fleming F, Khursigara N, O’Connell N, Darby S, Waldron D. Fulminant small bowel enteritis: a rare complication of clostridium difficile-associated disease. Inflamm Bowel Dis 2009 Jun;15(6):801e2. [26] Williams RN, Hemingway D, Miller AS. Enteral clostridium difficile, an emerging cause for high-output ileostomy. J Clin Pathol 2009 Oct;62(10):951e3. [27] Boland E, Thompson JS. Fulminant clostridium difficile enteritis after proctocolectomy and ileal pouch-anal anastamosis. Gastroenterol Res Pract 2008;2008:985658. [28] Navaneethan U, Giannella RA. Thinking beyond the colon-small bowel involvement in clostridium difficile infection. Gut Pathog 2009 Mar 19;1(1):7. [29] Malkan AD, Pimiento JM, Maloney SP, Palesty JA, Scholand SJ. Unusual manifestations of clostridium difficile infection. Surg Infect (Larchmt) 2010 Jun;11(3):333e7. [30] Kurtz LE, Yang SS, Bank S. Clostridium difficile-associated small bowel enteritis after total proctocolectomy in a crohn’s disease patient. J Clin Gastroenterol 2010 Jan;44(1):76e7. [31] Gagandeep D, Ira S. Clostridium difficile enteritis 9 years after total proctocolectomy: a rare case report. Am J Gastroenterol 2010 Apr;105(4):962e3. [32] Holmer C, Zurbuchen U, Siegmund B, Reichelt U, Buhr HJ, Ritz JP. Clostridium difficile infection of the small bowel-two case reports with a literature survey. Int J Colorectal Dis; 2010 Jul 14 [Epub ahead of print]. [33] Testore GP, Nardi F, Babudieri S, Giuliano M, Di Rosa R, Panichi G. Isolation of clostridium difficile from human jejunum: identification of a reservoir for disease? J Clin Pathol 1986 Aug;39(8):861e2. [34] Triadafilopoulos G, Pothoulakis C, O’Brien MJ, LaMont JT. Differential effects of Clostridium difficile toxins A and B on rabbit ileum. Gastroenterology 1987 Aug;93(2):273e9. [35] Neut C, Bulois P, Desreumaux P, Membré JM, Lederman E, Gambiez L, et al. Changes in the bacterial flora of the neoterminal ileum after ileocolonic resection for crohn’s disease. Am J Gastroenterol 2002 Apr;97(4):939e46. [36] Apel R, Cohen Z, Andrews Jr CW, McLeod R, Steinhart H, Odze RD. Prospective evaluation of early morphological changes in pelvic ileal pouches. Gastroenterology 1994 Aug;107(2):435e43. [37] O’Connor JR, Johnson S, Gerding DN. Clostridium difficile infection caused by the epidemic BI/NAP1/027 strain. Gastroenterology 2009 May;136(6):1913e24. [38] Keel MK, Songer JG. The distribution and density of clostridium difficile toxin receptors on the intestinal mucosa of neonatal pigs. Vet Pathol 2007 Nov;44(6):814e22. [39] Ananthakrishnan AN, McGinley EL, Binion DG. Excess hospitalisation burden associated with clostridium difficile in patients with inflammatory bowel disease. Gut 2008 Feb;57(2):205e10. [40] McFarland LV, Surawicz CM, Stamm WE. Risk factors for clostridium difficile carriage and C. difficile-associated diarrhea in a cohort of hospitalized patients. J Infect Dis 1990 Sep;162(3):678e84. [41] Kyne L, Warny M, Qamar A, Kelly CP. Asymptomatic carriage of Clostridium difficile and serum levels of IgG antibody against toxin A. N Engl J Med 2000 Feb 10;342(6):390e7.
Contents lists available at ScienceDirect
Anaerobe journal homepage: www.elsevier.com/locate/anaerobe
Clostridium difficile enteritis: A review and pooled analysis of the cases J.H. Kim a, R.R. Muder a, b, * a b
Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA Infectious Disease Section, VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 8 November 2010 Received in revised form 9 February 2011 Accepted 12 February 2011 Available online 18 February 2011
Introduction: Clostridium difficile is the most common cause of healthcare-associated infection diarrhea and usually restricted to infection of the colon. However, small bowel involvement of C. difficile infection has been reported. We performed a literature review and pooled analysis of the reported cases of C. difficile enteritis Method: A Pubmed literature database search and pooled analysis of the reported cases of C. difficile enteritis. Results: 56 cases of C. difficile enteritis have been reported from 1980 to 2010; 48 cases were published since 2001. Median age was 55 years. 27 patients (48.2%) were female. 29 patients (51.8%) had inflammatory bowel disease (IBD) e Crohn’s disease or ulcerative colitis and 20 patients (35.7%) had predisposing medical condition(s) that might lead to an immunoincompetent state. 33 patients (58.9%) had colectomy with ileostomy and 13 patients (23.2%) had other small and/or large bowel surgery. Thirty four patients (60.7%) received ICU management and 18 patients (32.1%) died. We categorized the patients into two groups, 38 survivors (67.9%) 18 non-survivors (32.1%). Significantly older age was noted in nonsurvivors. Median age was 48 years and 66 years, respectively for survivors and non-survivors, P < 0.001. There were more patients with predisposing medical condition(s) among non-survivors, (13/18, 72.2%) than among survivors (7/38, 18.4%), P < 0.001. Conclusions: C. difficile enteritis is still rare, however it seems to be increasingly reported in recent years. Surgically altered intestinal anatomies, advanced age, predisposing medical condition(s) that might lead to immunoincompetence appear to be at risk for developing C. difficile enteritis. Recognition of C. difficile infection not only in the colon but also in the small bowel may lead to improved outcomes. Published by Elsevier Ltd.
Keywords: Clostridium difficile Enteritis
1. Introduction Clostridium difficile is the most common cause of healthcareassociated infectious diarrhea [1]; it is usually restricted to infection of the colon [2]. However, in rare circumstances, small bowel involvement of C. difficile infection has been reported. A severe clinical course leading to significant morbidity and mortality rates has been demonstrated in this small subset of patients with C. difficile infection. In this article, we present a review and pooled analysis of the reported cases of C. difficile enteritis. 2. Method We searched PubMed using the terms “enteritis” and “clostridium difficile”, and resulting English language entries were reviewed individually. All publications reporting cases of C. difficile e * Corresponding author. Infectious Disease Section, VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240, USA. Tel.: þ1 412 360 6179; fax: þ1 412 360 6950. E-mail address: [email protected] (R.R. Muder). 1075-9964/$ e see front matter Published by Elsevier Ltd. doi:10.1016/j.anaerobe.2011.02.002
associated small bowel enteritis were included in this review and pooled analysis. In addition, the references of these case reports were reviewed to find additional reported cases. The following data were extracted and categorized into variables: demographics including age and sex, pre-existing gastrointestinal disease conditions including presence of inflammatory bowel disease (ulcerative colitis or Crohn’s disease), predisposing medical condition(s) that might lead to immunoincompetence (malignancy, solid organ transplant recipient, liver cirrhosis, end stage renal disease, HIV, and active tuberculosis on treatment), previous C. difficile infection, previous gastrointestinal surgery (colectomy with ileostomy, other small bowel and/or large bowel surgery, surgeries of pelvis, rectum, prostate, gallbladder), recent antibiotic use, hospitalization before the onset of C. difficile enteritis, medical and surgical treatment for C. difficile small bowel enteritis, intensive care unit (ICU) transfer, and death. 2.1. Statistical analysis of pooled data We summarized each of the selected studies by recording these categorized variables and conducted a descriptive analysis. Then
J.H. Kim, R.R. Muder / Anaerobe 17 (2011) 52e55
we compared patients who survived with those who died. Pooled data in this study were analyzed using two-sided ManneWhitney test or Fisher’s exact test. SPSS, version 15.0 was used for the analysis. P values of less than 0.05 were considered to indicate statistical significance. 3. Result The Pubmed literature search revealed total of 56 cases from 1980 to 2010; 48 cases were published since 2001 [3e32]. The diagnosis of C. difficile enteritis was based on the following; 1. Positive C. difficile toxin in stool or ileostomy output in patients who previously had had colectomy with ileostomy (23 cases). 2. Positive C. difficile toxin in increased ileostomy output in patients with formation of ileostomy postoperatively (3 cases). 3. Autopsy, surgical pathology, or biopsy showing histologic evidence of enteritis with positive C. difficile toxin and/or C. difficile isolated on culture (30 cases). Median age was 55 years with interquartile range (IQR) of 41e70 years. 27 patients (48.2%) were female. 29 patients (51.8%) had inflammatory bowel disease (IBD) e Crohn’s disease or ulcerative colitis and 20 patients (35.7%) had predisposing medical condition(s) that might lead to an immunoincompetent state. Only 10 patients (17.9%) were noted to have neither IBD nor predisposing medical condition(s). 33 patients (58.9%) had colectomy with ileostomy and 13 patients (23.2%) had other small and/or large bowel surgery. The majority had recent antibiotic therapy (50 patients, 89.3%). Thirty four patients (60.7%) received ICU management and 18 patients (32.1%) died. Median time between the onset of symptoms or diagnosis of C. difficile enteritis and death was 4 days with IQR 2e20 days. These are shown in Table 1. Several interesting features of 29 IBD patients were noted: median age was younger (44 years) with IQR of 31e54 years: the majority of IBD patients (24 patients, 82.8%) had colectomy with ileostomy: only a few patients (3 patients, 10.3%) had predisposing medical condition(s) other than IBD: the mortality in this group was lower than that of the whole group (3 patients, 10.3%). We categorized the patients into two groups, 38 survivors (67.9%) 18 non-survivors (32.1%) for further analysis. Significantly older age was noted in non-survivors. Median age was 48 years with IQR 34e60 years and 66 years with IQR 60e76 years, respectively for survivors and non-survivors, P < 0.001. The presence of IBD was significantly different in these two groups. More survivors (26/38, 68.4%) had IBD than those who died (3/18, 16.7%), P < 0.001. There were more patients with predisposing medical condition(s) among non-survivors, (13/18, 72.2%) than among survivors (7/38, 18.4%), P < 0.001. Although the majority of patients had previous gastrointestinal (GI) surgery, types of previous GI surgery was significantly different between these two groups. More survivors had colectomy with (27/38, 71.1%) than non-survivors (6/18, 33.3%), P ¼ 0.010. Non-survivors required significantly more ICU management (17/18, 94.4%) than did survivors 17 patients (17/38, 44.7%). No significant differences were found among other clinical variables between two groups. These are shown in Table 2. 4. Discussion C. difficile is usually considered to be a colonic pathogen and is a common cause of antibiotic-associated diarrhea and colitis. Although C. difficile enteritis is quite rare, it has been increasingly recognized recently. Until the year 2000, 8 reports with 8 cases had been published [3e14]. The literature reveals an increasing number of 22 reports with 48 cases since 2001 [15e32]. Of the 56 cases reported so far, a total of 18 deaths were recorded, resulting in an overall mortality figure of 32.1%.
53
Table 1 Characteristics of previously published cumulative cases of C. difficile enteritis. Total number of patients: 56 Age (median, IQR)
55 (41e70)
Sex Female (%) Male (%)
27 (48.2) 29 (51.8)
IBDa (%) Predisposing medical conditionb (%) IBD and/or predisposing medical condition (%) Previous GI surgery* Colectomy with ileostomy (%) Other small/large bowel surgery (%) Other surgery (no small/large bowel) (%) No known previous GI surgery (%)
29 (51.8) 20 (35.7) 46 (82.1) 33 13 5 5
(58.9) (23.2) (8.9) (8.9)
Past C. difficile infection No past C. difficile infection (%) Past C. difficile infection (%) Unknown (%)
7 (12.5) 11 (19.6) 38 (67.9)
Recent antibiotic use No recent antibiotic use (%) Recent antibiotic use (%) Unknown (%)
5 (8.9) 50 (89.3) 1 (1.8)
Recent hospitalization No recent hospitalization (%) Recent hospitalization (%) Unknown (%)
7 (12.5) 33 (58.9) 10 (17.9)
ICU transfer No ICU transfer (%) ICU transfer (%) Unknown (%)
12 (21.4) 34 (60.7) 10 (17.9)
Death No death (%) Death (%) Time to death (days), median (IQR)
38 (67.9) 18 (32.1) 4 (2e20)
*Previous GI surgery Colectomy with ileostomy; total or proctocolectomy with ileostomy. Other small/large bowel surgery; subtotal colectomy, hemicolectomy, other small and/or large bowel surgery. Other surgery (no small/large bowel); other surgeries including prostate, gallbladder, bladder, pelvic without previous small and/or large bowel surgery. a IBD; inflammatory bowel disease including either Ulcerative Colitis or Crohn’s disease. b Predisposing medical condition; condition(s) including malignancy, solid organ transplant recipient, liver cirrhosis, end stage renal disease, HIV, and active tuberculosis on treatment which might lead to immunoincompetence.
The pathophysiology of C. difficile small bowel enteritis is not completely understood. Its association with severe disease course and a recent increase in reported cases is still unclear. However, there appears to be several factors to consider. C. difficile has been shown to be in the jejunum; the small bowel may serve as a reservoir for C. difficile [33]. In a rabbit ileal loop model, C. difficile toxin A (TcdA) has been shown to generate severe inflammatory enteritis, pathologic findings similar to those in human C. difficile infection [34]. The majority of patients we reviewed (46 patients, 82.1%) had previous GI surgery including colectomy with ileostomy, other small and/or large bowel surgery. Changes such as colonization of the neoterminal ileum by colonictype bacterial flora [35] and phenotypic changes in the epithelium of pelvic ileoanal pouches [36] have been reported after colectomy. These factors may facilitate colonization of fecal flora with overgrowth of C. difficile in the small bowel. Also majority of patients (50 patients, 89.3%) had recent antibiotic use prior to the development of C. difficile small bowel enteritis, likely resulting in
54
J.H. Kim, R.R. Muder / Anaerobe 17 (2011) 52e55
Table 2 Comparison of survivors and non-survivors in previously published cumulative cases of C. difficile enteritis. Survivors Non-survivors P N ¼ 38/56, 67.9% N ¼ 18/56, 32.1% Age (median, IQR)
48 (34e60)
66 (60e76)
<0.001
Presence of IBD (%) Predisposing medical condition (%)
26 (68.4) 7 (18.4)
3 (16.7) 13 (72.2)
<0.001 <0.001
27 (71.1) 6 (15.8)
6 (33.3) 7 (38.9)
0.010 0.089
1 (2.6)
4 (22.2)
0.033
4 (10.5)
1 (5.6)
1.000
Past C. difficile infection No past C. difficile infection (%) 6 (15.8) Past C. difficile infection (%) 9 (23.7) Unknown (%) 23 (60.5)
1 (5.6) 2 (11.1) 15 (83.3)
0.409 0.473 0.128
Recent antibiotic use No recent antibiotic use (%) Recent antibiotic use (%) Unknown (%)
4 (10.5) 33 (86.8) 1 (2.6)
1 (5.6) 17 (94.4) 0 (0.0)
1.000 0.652 1.000
Recent hospitalization No recent hospitalization (%) Recent hospitalization (%) Unknown (%)
6 (15.8) 22 (57.9) 10 (26.3)
1 (5.6) 11 (61.1) 6 (33.3)
0.409 1.000 0.752
ICU transfer No ICU transfer (%) ICU transfer (%) Unknown (%)
12 (31.6) 17 (44.7) 9 (23.7)
0 (0.0) 17 (94.4) 1 (5.6)
0.006 <0.001 0.143
8 13 13 1
3 4 10 1
Previous GI surgery Colectomy with ileostomy (%) Other small/large bowel surgery (%) Other surgery (no small/large bowel) (%) No known previous GI surgery (%)
Medical treatment^ Metro (%) Vanco (%) Metro and vanco (%) Metro and vanco and rifampin (%) Unknown or no treatment (%) Other treatment (%) Surgical treatment No surgery (%) Surgery (%)
(21.1) (34.2) (34.2) (2.6)
(16.7) (22.2) (55.6) (5.6)
1.000 0.535 0.155 0.544
2 (5.3) 1 (2.6)
0 (0.0) 0 (0.0)
1.000 1.000
29 (76.3) 9 (23.7)
9 (50.0) 9 (50.0)
0.068
^Medical treatment: Metro; metronidazole, Vanco; vancomycin, Other treatment; streptomycin.
eradication of other endogenous bowel flora and facilitating the proliferation of C. difficile. Therefore, a similar process of mucosal damage and inflammation mediated by enterotoxin produced during the proliferation of C. difficile may occur in the small bowel. The rates and severity of C. difficile infection in hospitals in North America and Europe have increased since 2000, largely due to dissemination of an epidemic strain, BI/NAP1/027 characterized by higher C. difficile toxin A (TcdA) and toxin B (TcdB) production from deletion of the tcdC gene [37]. In a neonatal pig model, TcdA binding was much more intense in the the small intestine, and experimental gavage of pigs with TcdA generated more severe lesions in the small intestine [38]. Thus, an epidemic strain, BI/NAP1/027 may be able to colonize and affect the small intestine more easily than previous strain, as suggested in one report [22]. Given the fact that 21 out of 22 published reports of C. difficile enteritis since 2001 were from North America and Europe, patients could have been infected by the epidemic strain. Thus, current C. difficile infection epidemics with BI/NAP1/027 strain may be
responsible for increased number of the cases recently, although cultures and typing of the strain data were not available for analysis. C. difficile infection in IBD patients has been reported to be associated with a higher mortality than in infection among those admitted to hospital for treatment of IBD alone or C. difficile infection alone [39]. However, among our patients, those with IBD and colectomy with ileostomy were more likely to survive. IBD patients who had C. difficile enteritis were younger, less likely to have concomitant condition(s), and more likely to receive medical attention due to their surgically e corrected pre-existing IBD condition. Therefore, IBD patients might have more physiologic reserve to mount an immune response against C. difficile enteritis than patients with more advanced age and predisposing medical condition(s). Advanced age and severe underlying illness have been identified as risk factors with increased risk of C. difficile carriage and diarrhea [40]. Host immunoglobulin G responses against C. difficile toxin A have been shown to protect against symptomatic C. difficile disease [41]. The majority of reported patients (46 patients, 82.1%) had IBD or predisposing medical condition(s) that might lead to immunoincompetence. And there were significantly more advanced older age and presence of predisposing medical condition(s) in non-survivors group. Taken together, our results support the idea that decreased immune response from advanced age and severe underlying illness may play a critical role in C. difficile small bowel enteritis. Our study has limitations, however, mostly stemming from its small sample size and its retrospective nature. First, C. difficile enteritis is a rare entity, however, C. difficile enteritis could have been more frequent and only severe cases would have been diagnosed and reported. Thus, it might reflect a selection bias toward C. difficile enteritis cases. Second, because cultures and typing of the strain data from C. difficile enteritis were not available, it was not possible to assess if the BI/NAP1/027 strain was responsible for cases. Third, there were no data measuring immunological markers such as immunoglobulin G levels against C. difficile toxin A, making difficult to evaluate whether decreased immune response was indeed attributable to development of symptomatic C. difficile enteritis with increased mortality. Finally, follow up was not available for all patients who survived. To our knowledge, this is the first pooled analysis comparing survival group and death group in C. difficile enteritis with a review of the literature. In conclusion, C. difficile enteritis is still rare, however it seems to be increasingly reported in recent years along with epidemic C. difficile BI/NAP1/027 strain with high mortality rates. Patients with surgically altered intestinal anatomies, advanced age, IBD, and predisposing medical condition(s) that might lead to immunoincompetence appear to be at risk for developing C. difficile enteritis. Early recognition of C. difficile infection not only in the colon but also in the small bowel might play a substantial role in preventing potential morbidity and mortality in this cohort of patients. References [1] Gerding DN, Johnson S, Peterson LR, Mulligan ME, Silva Jr J. Clostridium difficile diarrhea and colitis. Infect Control Hos Epidemiol 1995;16:459e77. [2] Bartlett JG. Clostridium difficile: clinical considerations. Rev Infect Dis 1990;12(suppl. 2):S243e51. [3] LaMont JT, Trnka YM. Therapeutic implications of clostridium difficile toxin during relapse of chronic inflammatory bowel disease. Lancet 1980 Feb 23;1(8165):381e3. [4] Shortland JR, Spencer RC, Williams JL. Pseudomembranous colitis associated with changes in an ileal conduit. J Clin Pathol 1983 Oct;36(10):1184e7. [5] Yee Jr HF, Brown Jr RS, Ostroff JW. Fatal clostridium difficile enteritis after total abdominal colectomy. J Clin Gastroenterol 1996 Jan;22(1):45e7.
J.H. Kim, R.R. Muder / Anaerobe 17 (2011) 52e55 [6] Miller DL, Sedlack JD, Holt RW. Perforation complicating rifampin-associated pseudomembranous enteritis. Arch Surg 1989 Sep;124(9):1082. [7] Kuntz DP, Shortsleeve MJ, Kantrowitz PA, Gauvin GP. Clostridium difficile enteritis. A cause of intramural gas. Dig Dis Sci 1993 Oct;38(10):1942e4. [8] Tsutaoka B, Hansen J, Johnson D, Holodniy M. Antibiotic-associated pseudomembranous enteritis due to clostridium difficile. Clin Infect Dis 1994 Jun;18(6):982e4. [9] Kralovich KA, Sacksner J, Karmy-Jones RA, Eggenberger JC. Pseudomembranous colitis with associated fulminant ileitis in the defunctionalized limb of a jejunal-ileal bypass. Report of a case. Dis Colon Rectum 1997 May;40(5):622e4. [10] Vesoulis Z, Williams G, Matthews BP. Seudomembranous enteritis after proctocolectomy: report of a case. Dis Colon Rectum 2000 Apr;43(4):551e4. [11] Tjandra JJ, Street A, Thomas RJ, Gibson R, Eng P, Cade J. Fatal clostridium difficile infection of the small bowel after complex colorectal surgery. ANZ J Surg 2001 Aug;71(8):500e3. [12] Jacobs A, Barnard K, Fishel R, Gradon JD. Extracolonic manifestations of Clostridium difficile infections. Presentation of 2 cases and review of the literature. Medicine (Baltimore) 2001 Mar;80(2):88e101. [13] Freiler JF, Durning SJ, Ender PT. Clostridium difficile small bowel enteritis occurring after total colectomy. Clin Infect Dis 2001 Oct 15;33(8):1429e31. [14] Mann SD, Pitt J, Springall RG, Thillainayagam AV. Clostridium difficile infectionean unusual cause of refractory pouchitis: report of a case. Dis Colon Rectum 2003 Feb;46(2):267e70. [15] Hayetian FD, Read TE, Brozovich M, Garvin RP, Caushaj PF. Ileal perforation secondary to Clostridium difficile enteritis: report of 2 cases. Arch Surg 2006 Jan;141(1):97e9. [16] Lundeen SJ, Otterson MF, Binion DG, Carman ET, Peppard WJ. Clostridium difficile enteritis: an early postoperative complication in inflammatory bowel disease patients after colectomy. J Gastrointest Surg 2007 Feb;11(2):138e42. [17] Kim KA, Wry P, Hughes Jr E, Butcher J, Barbot D. Clostridium difficile smallbowel enteritis after total proctocolectomy: a rare but fatal, easily missed diagnosis. Report of a case. Dis Colon Rectum 2007 Jun;50(6):920e3. [18] Follmar KE, Condron SA, Turner II , Nathan JD, Ludwig KA. Treatment of metronidazole-refractory clostridium difficile enteritis with vancomycin. Surg Infect (Larchmt) 2008 Apr;9(2):195e200. [19] Wood MJ, Hyman N, Hebert JC, Blaszyk H. Catastrophic clostridium difficile enteritis in a pelvic pouch patient: report of a case. J Gastrointest Surg 2008 Feb;12(2):350e2. [20] Yafi FA, Selvasekar CR, Cima RR. Clostridium difficile enteritis following total colectomy. Tech Coloproctol 2008 Mar;12(1):73e4. [21] Wee B, Poels JA, McCafferty IJ, Taniere P, Olliff J. A description of CT features of clostridium difficile infection of the small bowel in four patients and a review of literature. Br J Radiol 2009 Nov;82(983):890e5. [22] Lavallée C, Laufer B, Pépin J, Mitchell A, Dubé S, Labbé AC. Fatal clostridium difficile enteritis caused by the BI/NAP1/027 strain: a case series of ileal C. difficile infections. Clin Microbiol Infect 2009 Dec;15(12):1093e9. [23] Causey MW, Spencer MP, Steele SR. Clostridium difficile enteritis after colectomy. Am Surg 2009 Dec;75(12):1203e6.
55
[24] Shen B, Remzi FH, Fazio VW. Fulminant clostridium difficile-associated pouchitis with a fatal outcome. Nat Rev Gastroenterol Hepatol 2009 Aug;6(8):492e5. [25] Fleming F, Khursigara N, O’Connell N, Darby S, Waldron D. Fulminant small bowel enteritis: a rare complication of clostridium difficile-associated disease. Inflamm Bowel Dis 2009 Jun;15(6):801e2. [26] Williams RN, Hemingway D, Miller AS. Enteral clostridium difficile, an emerging cause for high-output ileostomy. J Clin Pathol 2009 Oct;62(10):951e3. [27] Boland E, Thompson JS. Fulminant clostridium difficile enteritis after proctocolectomy and ileal pouch-anal anastamosis. Gastroenterol Res Pract 2008;2008:985658. [28] Navaneethan U, Giannella RA. Thinking beyond the colon-small bowel involvement in clostridium difficile infection. Gut Pathog 2009 Mar 19;1(1):7. [29] Malkan AD, Pimiento JM, Maloney SP, Palesty JA, Scholand SJ. Unusual manifestations of clostridium difficile infection. Surg Infect (Larchmt) 2010 Jun;11(3):333e7. [30] Kurtz LE, Yang SS, Bank S. Clostridium difficile-associated small bowel enteritis after total proctocolectomy in a crohn’s disease patient. J Clin Gastroenterol 2010 Jan;44(1):76e7. [31] Gagandeep D, Ira S. Clostridium difficile enteritis 9 years after total proctocolectomy: a rare case report. Am J Gastroenterol 2010 Apr;105(4):962e3. [32] Holmer C, Zurbuchen U, Siegmund B, Reichelt U, Buhr HJ, Ritz JP. Clostridium difficile infection of the small bowel-two case reports with a literature survey. Int J Colorectal Dis; 2010 Jul 14 [Epub ahead of print]. [33] Testore GP, Nardi F, Babudieri S, Giuliano M, Di Rosa R, Panichi G. Isolation of clostridium difficile from human jejunum: identification of a reservoir for disease? J Clin Pathol 1986 Aug;39(8):861e2. [34] Triadafilopoulos G, Pothoulakis C, O’Brien MJ, LaMont JT. Differential effects of Clostridium difficile toxins A and B on rabbit ileum. Gastroenterology 1987 Aug;93(2):273e9. [35] Neut C, Bulois P, Desreumaux P, Membré JM, Lederman E, Gambiez L, et al. Changes in the bacterial flora of the neoterminal ileum after ileocolonic resection for crohn’s disease. Am J Gastroenterol 2002 Apr;97(4):939e46. [36] Apel R, Cohen Z, Andrews Jr CW, McLeod R, Steinhart H, Odze RD. Prospective evaluation of early morphological changes in pelvic ileal pouches. Gastroenterology 1994 Aug;107(2):435e43. [37] O’Connor JR, Johnson S, Gerding DN. Clostridium difficile infection caused by the epidemic BI/NAP1/027 strain. Gastroenterology 2009 May;136(6):1913e24. [38] Keel MK, Songer JG. The distribution and density of clostridium difficile toxin receptors on the intestinal mucosa of neonatal pigs. Vet Pathol 2007 Nov;44(6):814e22. [39] Ananthakrishnan AN, McGinley EL, Binion DG. Excess hospitalisation burden associated with clostridium difficile in patients with inflammatory bowel disease. Gut 2008 Feb;57(2):205e10. [40] McFarland LV, Surawicz CM, Stamm WE. Risk factors for clostridium difficile carriage and C. difficile-associated diarrhea in a cohort of hospitalized patients. J Infect Dis 1990 Sep;162(3):678e84. [41] Kyne L, Warny M, Qamar A, Kelly CP. Asymptomatic carriage of Clostridium difficile and serum levels of IgG antibody against toxin A. N Engl J Med 2000 Feb 10;342(6):390e7.