Альманах клинической медицины. 2018; 46: 474-481
Clostridium difficile при язвенном колите. Ретроспективное исследование
https://doi.org/10.18786/2072-0505-2018-46-5-474-481Аннотация
Цель – изучить эпидемиологию, факторы риска возникновения клостридиальной инфекции (КДИ), связанной с Clostridium difficile, частоту колэктомии у пациентов с язвенным колитом (ЯК). Материал и методы. В ретроспективном исследовании было проанализировано 1179 медицинских карт пациентов с воспалительными заболеваниями кишечника, лечившихся с 1 января по 31 декабря 2017 г. в ГБУЗ МКНЦ имени А.С. Логинова ДЗМ. Диагноз ЯК устанавливали согласно критериям Международной классификации болезней 10-го пересмотра (МКБ-10: K51). В окончательный анализ включены данные 400 пациентов с ЯК. В зависимости от наличия предварительного диагноза КДИ пациентов разделили на две группы: 79 (19,75%) пациентов с ЯК имели хотя бы 1 подтвержденный эпизод КДИ, 321 (80,25%) не имел перенесенной в прошлом КДИ. Результаты. Частота КДИ среди пациентов с ЯК составила 19,75%, при этом 88,6% инфекций были внебольничными и лишь 5,1% возникли в медицинских учреждениях. Средний возраст возникновения КДИ у пациентов с воспалительными заболеваниями кишечника составил 37,8 ± 12,9 года. Только у 13,4% пациентов с ЯК, ассоциированным с КДИ, в анамнезе были указания на использование антибиотиков, а 40,5% ранее применяли стероиды. Длительная иммуносупрессивная терапия у пациентов с ЯК оказывала влияние на развитие КДИ: среди пациентов с КДИ 41,8% длительно получали азатиоприн/6-меркаптопурин, без КДИ – 14,6% (p < 0,001). Частота КДИ у больных ЯК, получавших терапию мезенхимальными, стромальными клетками костного мозга, была статистически значимо ниже, чем у больных ЯК, получавших терапию генно-инженерными биологическими препаратами, как в комбинации с иммуносупрессорами, так и без них (p < 0,05). Хирургическое вмешательство (колэктомия) потребовалось 3 из 4 больных со сверхтяжелым ЯК, ассоциированным с КДИ, и 2 из 18 пациентов со сверхтяжелой атакой без КДИ. Заключение. Пациенты с ЯК молодого возраста более восприимчивы к КДИ и часто не имеют традиционных факторов риска. Значимую роль в развитии КДИ у пациентов с ЯК могут играть другие факторы риска, чем в общей популяции. У больных ЯК с КДИ в анамнезе чаще отмечается неэффективность терапии салицилатами, чаще требуется назначение биологической терапии, они имеют более низкое среднее значение альбумина и более высокую активность воспалительного процесса. Сверхтяжелая атака ЯК, ассоциированного с КДИ, статистически значимо повышает риск колэктомии.
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20. Regnault H, Bourrier A, Lalande V, Nion-Larmurier I, Sokol H, Seksik P, Barbut F, Cosnes J, Beaugerie L. Prevalence and risk factors of Clostridium difficile infection in patients hospitalized for flare of inflammatory bowel disease: a retrospective assessment. Dig Liver Dis. 2014;46(12):1086-92. doi: 10.1016/j.dld.2014.09.003.
21. Masclee GM, Penders J, Jonkers DM, Wolffs PF, Pierik MJ. Is clostridium difficile associated with relapse of inflammatory bowel disease? Results from a retrospective and prospective cohort study in the Netherlands. Inflamm Bowel Dis. 2013;19(10):2125-31. doi: 10.1097/MIB.0b013e318297d222.
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27. Kim DB, Lee KM, Park SH, Kim YS, Kim ES, Lee J, Jung SA, Seo GS, Lee JM. Is Clostridium difficile infection a real threat in patients with ulcerative colitis? A prospective, multicenter study in Korea. Intest Res. 2018;16(2):267-72. doi: 10.5217/ir.2018.16.2.267.
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Almanac of Clinical Medicine. 2018; 46: 474-481
Clostridium difficile in ulcerative colitis; a retrospective study
https://doi.org/10.18786/2072-0505-2018-46-5-474-481Abstract
Aim: To study epidemiology and risk factors of Clostridium difficile infection (CDI) and its association with colectomy rates in patients with ulcerative colitis (UC). Materials and methods: We retrospectively analyzed medical files of 1179 patients with inflammatory bowel disease who had been treated from January 1 to December 31, 2017, in the Loginov Moscow Clinical Scientific Center (Moscow, Russia). UC was diagnosed according to the International Classification of Diseases, v. 10 (ICD10: K51). Final analysis included data from 400 UC patients. Depending on the presence of preliminary CDI diagnosis, the patients were divided into two groups: 79 (19.75%) patients with UC had at least one confirmed CDI episode, whereas 321 (80.25%) patients had no history of CDI. Results: CDI prevalence in UC patients was 19.75%, and 88.6% of the infectious episodes were community-acquired, whereas only 5.1% occurred in the inpatients. Mean (± SD) age at CDI occurrence in patients with inflammatory bowel disease was 37.8 ± 12.9 years. Only 13.4% of the patients with UC and associated CDI had the history of antibiotic therapy, and 40.5% had been previously treated with steroids. Prolonged immunosuppressive therapy in UC patients was associated with CDI: 41.8% of those with CDI had been treated with azathioprine/6-mercaptopurin for a long time, while among those without CDI this treatment had been administered only to 14.6% (p < 0.001). CDI prevalence in the UC patients who had been treated with mesenchymal stromal bone marrow cells was significantly lower than in those who had been treated with genetically engineered biological agents, both with and without immunosuppressants (p < 0.05). Surgery (colectomy) was necessary in 3 out of 4 patients with extremely severe UC associated with CDI, and in 2 out of 18 patients with extremely severe UC exacerbation without CDI. Conclusion: Young UC patients are more susceptible to CDI and often do not have any conventional CDI risk factors. In UC patients, other risk factors than in the general population, may have a significant impact on the CDI occurrence. UC patients with CDI more often have a history of salicylate failure, they more frequently require biological treatments, have lower mean albumin levels and higher activity of the inflammation. Extremely severe UC episode associated with CDI significantly increases the risk of colectomy.
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22. Ott C, Girlich C, Klebl F, Plentz A, Iesalnieks I, Scholmerich J, Obermeier F. Low risk of Clostridium difficile infections in hospitalized patients with inflammatory bowel disease in a German tertiary referral center. Digestion. 2011;84(3):187-92. doi: 10.1159/000324617.
23. Kim J, Pai H, Seo MR, Kang JO. Epidemiology and clinical characteristics of Clostridium difficile infection in a Korean tertiary hospital. J Korean Med Sci. 2011;26(10):1258-64. doi: 10.3346/jkms.2011.26.10.1258.
24. Sinh P, Barrett TA, Yun L. Clostridium difficile infection and inflammatory bowel disease: a review. Gastroenterol Res Pract. 2011;2011:136064. doi: 10.1155/2011/136064.
25. Roy A, Lichtiger S. Clostridium difficile infection: a rarity in patients receiving chronic antibiotic treatment for Crohn's disease. Inflamm Bowel Dis. 2016;22(3):648-53. doi: 10.1097/MIB.0000000000000641.
26. Murthy SK, Steinhart AH, Tinmouth J, Austin PC, Daneman N, Nguyen GC. Impact of Clostridium difficile colitis on 5-year health outcomes in patients with ulcerative colitis. Aliment Pharmacol Ther. 2012;36( 11-12): 1032-9. doi: 10.1111/apt.12073.
27. Kim DB, Lee KM, Park SH, Kim YS, Kim ES, Lee J, Jung SA, Seo GS, Lee JM. Is Clostridium difficile infection a real threat in patients with ulcerative colitis? A prospective, multicenter study in Korea. Intest Res. 2018;16(2):267-72. doi: 10.5217/ir.2018.16.2.267.
28. Tae CH, Jung SA, Song HJ, Kim SE, Choi HJ, Lee M, Hwang Y, Kim H, Lee K. The first case of antibiotic-associated colitis by Clostridium difficile PCR ribotype 027 in Korea. J Korean Med Sci. 2009;24(3):520-4. doi: 10.3346/jkms.2009.24.3.520.
29. Ben-Horin S, Margalit M, Bossuyt P, Maul J, Shapira Y, Bojic D, Chermesh I, Al-Rifai A, Schoepfer A, Bosani M, Allez M, Lakatos PL, Bossa F, Eser A, Stefanelli T, Carbonnel F, Katsanos K, Checchin D, de Miera IS, Reinisch W, Chowers Y, Moran GW; European Crohn's and Colitis Organization (ECCO). Prevalence and clinical impact of endoscopic pseudomembranes in patients with inflammatory bowel disease and Clostridium difficile infection. J Crohns Colitis. 2010;4(2):194-8. doi: 10.1016/j.crohns.2009.11.001.
30. Goodhand JR, Alazawi W, Rampton DS. Systematic review: Clostridium difficile and inflammatory bowel disease. Aliment Pharmacol Ther. 2011;33(4):428-41. doi: 10.1111/j.1365-2036.2010.04548.x.
