Risk of Clostridium Difficile Infection in Patients With Celiac Disease

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Clostridium difficile (C.diff) is a widely prevalent bacterium that causes abdominal cramping and diarrhea in affected individuals. In the United States, close to half a million people contract C.diff infection each year, and approximately 1.5% of those infected die as a direct result of the bacterium. Infection rates are highest in the elderly and in those who have recently been treated with antibiotics, but C.diff is increasingly being diagnosed in the broader community.

Studies have already shown that patients with celiac disease are at greater susceptibility to many common infections, including influenza, pneumonia, and tuberculosis. A recent study, published in the December 2017 volume of The American Journal of Gastroenterology, sought to examine whether celiac disease patients are similarly vulnerable to C.diff, particularly in light of the already observed prevalence of infection in patients with irritable bowel syndrome (IBS).

This large, population-based study identified 28,339 Swedish patients who were diagnosed with celiac disease via intestinal biopsy between 1969 and 2008. Using the Swedish Total Population Register, each study subject was matched for age, gender, and county, with up to five controls. Subjects were then followed for an average of 11 years to determine whether or not C.diff infection occurred. Statistical analyses were performed with adjustments for a number of variables, including educational attainment, healthcare usage (number of outpatient doctor visits), and medication use (specifically antibiotics and acid reducers).

Overall, analysis revealed that celiac disease patients had double the rate of C.diff diagnosis compared to matched controls, and that risk was highest in the first year following celiac disease diagnosis. By five years post diagnosis, there was no longer a statistical difference between infection rate in celiac disease patients and controls. One possible explanation for this pattern is that patients with untreated celiac disease may have increased inflammation and damage in the intestines, rendering them more vulnerable to infectious agents.

Use of acid reducers (proton pump inhibitors or PPIs) was not found to have a significant relationship with C.diff infection in either celiac disease patients or controls.

According to Benjamin Lebwohl, MD, first author of the study and Celiac Disease Foundation Medical Advisory Board member, “An important take-home message is that when people with celiac disease develop persistent diarrhea, it is not necessarily due to gluten exposure, or to refractory celiac disease. It could be something else, such as C. difficile.” Dr. Lebwohl added that “clinicians should keep an open mind and consider infections such as this when evaluating people with celiac disease who have persistent diarrhea.”

Interestingly, but not entirely surprisingly, the statistical difference between rates of infection in celiac disease patients and controls became insignificant when adjusting for the number of doctor visits per year. C.diff is excreted in feces, and inadequate sanitation (i.e. handwashing, equipment cleaning) can easily lead to transmission. Healthcare settings such as hospitals and nursing homes are at especially high risk, and more exposure to such settings means more opportunity for infection transmission. Even so, this study certainly suggests that healthcare practitioners should consider regular testing for C.diff in their celiac disease patients with persistent symptoms.

Click here to read the full study. Risk of Clostridium Difficile Infection in Patients With Celiac Disease

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Risk of Clostridium Difficile Infection in Patients With Celiac Disease

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