Is Clostridioides difficile superinfection a major causative factor for acute flares associated with moderate to severe ulcerative colitis in northern India?

BACKGROUND: The natural history of ulcerative colitis is characterized by the occurrence of recurrent flares. Flares in ulcerative colitis may be attributed to the natural history of the disease or other extraneous factors. Two important causes for iatrogenic flares are Clostridioides difficile infection and cytomegalovirus (CMV) colitis. We evaluated the prevalence of Clostridioides difficile infection in patients with moderate to severe ulcerative colitis admitted to a tertiary care hospital.

METHODS: This prospective study carried out at a tertiary care center in India evaluated patients of ulcerative colitis who presented with an acute flare of the disease over a 13-month period from May 2023 to May 2024. An enquiry of antibiotic exposure in the preceding eight weeks prior to the current admission was obtained. Simultaneous testing of glutamate dehydrogenase (GDH) and Clostridioides difficile toxin assay was done in all patients within 24 hours of admission by the enzyme-linked immunosorbent assay (ELISA) technique.

RESULTS: Of the 140 patients with an acute flare associated with ulcerative colitis who were evaluated for Clostridioides difficile infection, four tested positive for both GDH and toxin A and/or B giving an overall prevalence of 2.9%. Two of these four (50%) patients had prior exposure to antibiotics at the time of admission. Each of the four patients with Clostridioides difficile infection had an uneventful recovery post treatment with oral vancomycin and metronidazole.

CONCLUSION: Our data suggests that C. difficile is not a major causative factor for flares in patients with moderate to severe ulcerative colitis at a tertiary care hospital in northern India.