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Enteric Infections Are Common in Patients with Flares of Inflammatory Bowel Disease

Axelrad, Jordan E. MD, MPH1,2; Joelson, Andrew MD2; Green, Peter H. R. MD2; Lawlor, Garrett MD2; Lichtiger, Simon MD2; Cadwell, Ken PhD3,4; Lebwohl, Benjamin MD, MS2

American Journal of Gastroenterology: October 2018 - Volume 113 - Issue 10 - p 1530–1539
doi: 10.1038/s41395-018-0211-8

OBJECTIVES: Few studies have examined the role of non-Clostridium difficileenteric infections in flares of inflammatory bowel disease (IBD). Our objective was to investigate enteric infection detected by multiplex PCR stool testing in patients with IBD.

METHODS: We performed a cross-sectional analysis of 9403 patients who underwent 13,231 stool tests with a gastrointestinal pathogen PCR panel during a diarrheal illness from March 2015 to May 2017. Our primary outcome was the presence of an infection. Secondary outcomes included endoscopic and histologic predictors of infection, and IBD outcomes following testing.

RESULTS: A total of 277 patients with Crohn's disease (CD), 300 patients with ulcerative colitis (UC), and 8826 patients without IBD underwent 454, 503, and 12,275 tests, respectively. Compared to patients without IBD, patients with IBD were less likely to test positive (CD 18.1%, UC 16.1%, no IBD 26.6%,p< 0.001). Compared to patients without IBD, CD had a higher prevalence of norovirus (p= 0.05) andCampylobacter(p= 0.043), whereas UC had a lower prevalence of norovirus (p= 0.001) and a higher prevalence ofCampylobacter(p= 0.013),Plesiomonas(p= 0.049), andEscherichia colispecies (p< 0.001). Of 77 patients who underwent endoscopy, there were no major endoscopic or histologic predictors of a positive test. Patients who tested negative were more likely to have IBD therapy escalated (p= 0.004). Enteric infection did not impact IBD outcomes following testing (log-rank 0.224).

CONCLUSIONS: Non-Clostridium difficileenteric infections were identified in 17% of symptomatic patients with IBD. Endoscopic and histologic findings may not differentiate flare from infection. Norovirus andE.colimay play an important role in flare of IBD.

1Inflammatory Bowel Disease Center, Division of Gastroenterology, Department of Medicine, NYU Langone Health, New York, NY, USA. 2Division of Digestive and Liver Disease, Department of Medicine, Columbia University Medical Center, New York, NY, USA. 3Kimmel Center for Biology and Medicine at the Skirball Institute, New York University School of Medicine, New York, NY, USA. 4Department of Microbiology, New York University School of Medicine, New York, NY, USA.

Correspondence: J.E.A. (email:

SUPPLEMENTARY MATERIAL accompanies this paper at,,,

Received 8 February 2018; accepted 29 June 2018; Published online 3 August 2018

© The American College of Gastroenterology 2018. All Rights Reserved.
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