The Prevalence and Risk Factors of <italic>Clostridium</italic> Infection in Inflammatory Bowel Disease: 10 Years of Korean Experience Based on the National Database
AIBD 2023
Background:
Clostridioides difficile infection (CDI) is a significant healthcare burden, particularly in patients with inflammatory bowel disease (IBD). This study seeks to understand the prevalence and incidence of CDI in IBD patients and compare it to the general population. Additionally, it aims to identify specific risk factors, including age, sex, comorbidities, and medication use, associated with CDI in IBD patients.
Methods:
The study analyzed 55,052 IBD patients aged 18 to 79 from 2008 to 2018 after having washout period of a year, using The International Classification of Diseases, 10th revision (ICD-10) diagnostic codes from the National Health Insurance Service (NHIS) database and the Rare Intractable Diseases (RID) database. For RID registration of IBD patients in Korea, clinical, endoscopic, and pathological diagnoses of IBD are required. A matched non-IBD reference population was selected from the NHIS database during the same study period at a matching ratio of 1:2. We excluded patients with a history of CDI before the index date. Patients with CDI were defined with diagnosis codes and medications such as metronidazole per oral (PO), vancomycin per oral (PO), or metronidazole intravenous (IV). The t-test and chi-square test were used as appropriate to compare data. Demographics, comorbidities, and IBD medications were analyzed. The Charlson comorbidity index (CCI) was used to assess the severity of underlying comorbidities. Year-end prevalence and cumulative incidence of CDI in Crohn’s disease (CD) and ulcerative colitis (UC) were investigated, comparing with the general population. Cox regression analysis identified risk factors associated with CDI in IBD patients.
Results:
From 2008 to 2018, there were 54,836 patients with IBD (38,231 UC patients and 16,605 CD patients) and 109,178 patients in the reference population. The mean age at CDI diagnosis in CD, UC and general population was 37.5 ± 19.8 years, 49.1 ± 18.6 years and 62.4 ± 13.9 years respectively (P< 0.001). The IBD patients with CDI were younger than general CDI patients. The annual prevalence of CDI in CD and UC has been increased. The risk of CDI was higher in CD and UC patients than in the matched reference group (hazard ratio (HR) 7.285; 95% confidence interval (CI) 5.388-9.851; P< 0.001 and hazard ratio (HR) 7.487; 95% confidence interval (CI) 5.796-9.670; p < 0.001 respectively). Among IBD patients, the risk factors that had a significant association with the occurrence of CDI were older age, female sex, high CCI scores and IBD related medication including 5-aminosalicylic acid (5-ASA), immunomodulators (azathioprine, mercaptopurine, cyclosporine, tacrolimus, and methotrexate), steroids, and biologics (infliximab, adalimumab, vedolizumab and ustekinumab). Especially, Steroid use for more than 90 days was statistically significant with CDI incidence.
Conclusions:
From 2008 to 2018, CDI prevalence increased in IBD patients, especially younger ones. CDI risk was higher in IBD patients compared to the general population. Factors like older age, female sex, high CCI scores, and specific IBD medications (5-ASA, immunomodulators, biologics, steroids) significantly associated with CDI occurrence. Long-term steroid use particularly increased CDI risk.
