People with celiac disease are at increased risk for infections such as tuberculosis, influenza, and pneumococcal pneumonia, but until now little was known about their risk for Clostridium difficile infection (CDI) or C. difficile. In a study conducted at Columbia University Mailman School of Public Health, Columbia University Medical Center, in collaboration with the Karolinska Intitute of Stockholm Sweden, researchers found that people with celiac disease also have higher rates of C. difficile infection. This raises the possibility that people with celiac disease may be more susceptible because of altered gut immunity or microbial composition. The findings are published online in the American Journal of Gastroenterology.
[Photo: Dr. Benjamin Lebhohl]
Clostridium difficile infection is associated with a high risk of morbidity and mortality in Western countries, with an estimated 453,000 cases and 29,300 related deaths in the U.S. in 2011. Rates are on the rise, and in addition to female, white race, and the elderly, studies have shown that patients with inflammatory bowel disease are at higher risk for C. difficile.
To assess the incidence of C-difficile and celiac disease, researchers analyzed a database consisting of all patients with celiac disease based on intestinal biopsies submitted to pathology departments throughout Sweden. Individuals were followed up for an average of 11.5 years. C. difficile infection was documented in 493 patients overall and in 136 patients with celiac disease. Patients were matched to non-celiac controls by age, sex, and year of diagnosis.
The researchers found that 56 out of 100,000 patients with celiac disease were diagnosed with C-difficile infection. The risk of infection was highest in the first 12 months after a celiac disease diagnosis, but persisted in the five years beyond the diagnosis. Dr. Lebwohl and colleagues found no significant differences in prior exposures to antibiotics between patients with or without celiac disease. In addition, after adjusting for proton pump inhibitor use (for reducing gastric acid production), the association between celiac disease and the development of C. difficile infection remained significant.
“Patients with celiac disease may be diagnosed with C. difficile infection more frequently because of increased opportunities for testing, given that celiac disease is a chronic condition that entails contact with the health care system,” said Dr. Benjamin Lebhohl, assistant professor of medicine and epidemiology and director of clinical research at the Celiac Disease Center at Columbia University. “But this increased contact with health care may also increase the risk for developing C. difficile infection, given the exposure to antibiotics or the presence of C. difficile in the health care setting.”
“Our findings add to the list of infections that have been associated with celiac disease,” said Dr. Lebwohl. “In patients with celiac disease who develop recurrent symptoms, and particularly if those symptoms include diarrhea, clinicians should not assume that gluten exposure is the culprit; clinicians should consider C. difficile infection.”
Co-authors are Drs. Yael Nobel and Peter Green of Columbia University Medical Center; Dr. Martin Blaser, New York University Langone Medical Center, New York; and Dr. Jonas Ludvigsson, Karolinska Institutet, Stockholm and Örebro University Hospital, Örebro University, Örebro, Sweden
The study was supported by the National Institutes of Health, grant R01 DK090989. The authors report no financial conflict.