Published online Sep 21, 2026. doi: 10.3748/wjg.118677
Revised: April 18, 2026
Accepted: June 4, 2026
Published online: September 21, 2026
Processing time: 206 Days and 12.7 Hours
Clostridioides difficile (C. difficile) colonization (CDC) has been suspected as a contributing factor to inflammatory bowel disease (IBD) activity. However, a major limitation of previous studies is that the majority of included patients had active IBD at baseline.
To evaluate the possible association between CDC and IBD activity in outpatients without disease activity at study inclusion.
This was a prospective cohort study conducted at a single tertiary care center. Adult patients with IBD in remission were included. Three stool samples were obtained per participant during a minimum follow-up period of 6 months. CDC was defined as the presence of a positive culture for C. difficile, a positive glutamate dehydrogenase test, and a negative toxin test in patients with remitted IBD. CDC incidence was calculated, and its association with IBD activity was assessed using Cox regression analysis. A P value ≤ 0.05 was considered statistically significant.
Of 250 eligible candidates, 101 were included; 59.4% were women, and the median age was 49.0 years. The baseline prevalence of CDC was 13.9%. Slightly more than two-thirds of participants remained in remission during follow-up. After a median follow-up of 420 days, the incidence of CDC was 8.2 per 100 person-years. No association was found between CDC and IBD activity. In multivariate analysis, only prior healthcare utilization (hazard ratio = 3.48, 95% confidence interval: 1.26-9.57, P = 0.016) remained statistically significantly associated with IBD activity.
No association was observed between CDC and IBD activity in this prospective study of patients with IBD in cli
Core Tip: This prospective study evaluated the association between Clostridioides difficile (C. difficile) colonization (CDC) and inflammatory bowel disease (IBD) flares in patients in remission at baseline. Using stringent diagnostic criteria, no association was observed between CDC and subsequent IBD activity during a median follow-up longer than 1 year. Although baseline prevalence and incidence of CDC were relatively high, C. difficile infection events were infrequent, and approximately 70% of participants remained free of disease flares. The observed association between younger age at IBD diagnosis and CDC warrants further investigation.
- Citation: Morado-Aramburo O, Ochoa-Hein E, Pérez-Gutiérrez MT, Sánchez-Cruz MN, Bobadilla-del-Valle M, Yamamoto-Furusho JK, Ponce-de-Leon A, Sifuentes-Osornio J. Association between Clostridioides difficile colonization and inflammatory bowel disease activity in outpatients with remission. World J Gastroenterol 2026; 32(35): 118677
- URL: https://www.wjgnet.com/1007-9327/full/v32/i35/118677.htm
- DOI: https://dx.doi.org/10.3748/wjg.118677
Clostridioides difficile (C. difficile) is the most frequent cause of healthcare-associated infections in the United States[1] and represents a significant source of disease burden in both hospital and community settings worldwide[2]. Risk factors for C. difficile infection (CDI) in both ambulatory and hospitalized patients include previous antibiotic and proton pump inhibitor use, chemotherapy, hospitalization, previous gastrointestinal surgery, advanced age, use of a nasogastric tube, and comorbidities[3-5]. These factors are largely similar to those associated with C. difficile colonization (CDC)[6].
In patients with inflammatory bowel disease (IBD), trends in CDI rates have been inconsistent, with both increases[7] and declines[8] reported over time. The frequency of CDI ranges between 5% and 20% in ambulatory[9-11] and hospitalized[12-14] patients with IBD, and incidence rates as high as 22.3 cases per 1000 hospitalized patients with IBD have been reported[12]. Both CDI and CDC are more frequent in patients with IBD than in the general population[8,15,16]. The annual detection rates of C. difficile per 100000 person-years (including CDI and CDC) have been reported to be 512 and 377 in patients with ulcerative colitis and Crohn’s disease, respectively, compared with 99 in healthy controls[16]. The risk is highest during the first year after IBD diagnosis[8] and in younger patients[17]. This increased susceptibility to CDI and CDC in patients with IBD may be related to the inflammatory milieu and an altered microbiome, which facilitate CDC and proliferation[18].
Risk factors for C. difficile test positivity (including CDI and CDC) in patients with IBD include a previous CDI event[11], ulcerative colitis[14,19], recent use of nonsteroidal anti-inflammatory drugs[13] or antacids[20], maintenance immunomodulator therapy[19], an emergency department visit within the preceding 12 weeks[11], and recent hospitalization[20]. Conversely, IBD itself has been described as a risk factor for CDI, especially in cases where the colon is involved[12,21] or when IBD is severe[22].
Despite inconsistent evidence regarding the association of CDI with increased mortality, colectomy rates, and length of hospital stay in patients with active IBD, there is no convincing evidence linking C. difficile detection with IBD activity[11,23]. This could be partly explained by diagnostic challenges, as CDI and IBD share common clinical features[16]. Addi
Additionally, the proposed cause-effect relationship between CDI/CDC and IBD activity is further challenged by evidence suggesting that CDI could be the result of severe, recurrent IBD flares rather than a precipitating factor[22]. A major limitation of previous studies is that most included patients had active IBD, making it difficult to distinguish between IBD activity, CDI, and CDC[13,14,16,20].
The primary objective of this study was to analyze the possible association between CDC and future IBD flares in outpatients without disease activity at study inclusion. The secondary objectives were: (1) To determine the incidence of new cases of CDC and CDI; (2) To identify possible risk factors for CDC; and (3) To assess the prevalence of risk factors for CDI and CDC in healthy participants without IBD.
A prospective cohort study was conducted in a public tertiary referral hospital in Mexico City between April 2017 and April 2019. The study was approved by the institutional review board (No. 2189), and all participants provided written informed consent before enrolment.
Adults older than 18 years with IBD in clinical and biochemical remission were included (IBD group), along with a control group of healthy adult blood donors without IBD. Patients with a CDI episode (defined according to the 2018 Infectious Diseases Society of America guidelines)[26] at study entry or within the 6 weeks preceding collection of the first stool sample were excluded.
Participants in both groups underwent a clinical and sociodemographic evaluation using a structured questionnaire; additional data during follow-up were obtained from electronic health records. In the IBD group, three stool samples were collected per participant: One at inclusion and the remaining two during follow-up, with a minimum interval of 3 months between samples. Participants in the healthy blood donor group provided a single stool sample. Additionally, all participants underwent the following tests at each study visit: Complete blood count, blood chemistry, erythrocyte sedimentation rate, C-reactive protein, and fecal calprotectin.
Clinical remission in participants with ulcerative colitis was defined as the presence of all of the following: (1) Fewer than three bowel movements per day; (2) Absence of bloody stools, rectal pain, or rectal tenesmus during the previous 3 months; and (3) A Mayo Clinical Score of ≤ 2[27]. Biochemical remission was defined as fecal calprotectin levels < 165 pg/g, normal erythrocyte sedimentation rate and C-reactive protein levels, and absence of anemia. If any of these markers were abnormal, IBD activity was presumed unless an alternative plausible cause was identified. Clinical remission in participants with Crohn’s disease was defined as the absence of symptoms and a Crohn’s disease activity index > 150[28]. Accordingly, IBD activity was defined by the presence of either clinical or biochemical markers of activity in the absence of CDI (as explained below).
Stool samples from participants in both groups were initially screened using a glutamate dehydrogenase (GDH) assay (VIDAS GDH; bioMérieux, Durham, NC, United States). Samples with positive results were subsequently tested using the Xpert® C. difficile/Epi toxin assay (Cepheid, Sunnyvale, CA, United States). To confirm the presence of C. difficile isolates, stool samples were cultured on cycloserine-cefoxitin-fructose agar and incubated under anaerobic conditions. Colonies grown on culture media were identified using a VITEK2 system (bioMérieux).
In both groups, CDC was defined as the presence of a positive culture for C. difficile and a positive GDH test in the absence of a positive toxin test. Participants who developed diarrhea during the study period were evaluated to exclude CDI (in the healthy blood donor group) or to differentiate between CDI and IBD activity (in the IBD group). A diagnosis of CDI was concluded when all of the following criteria were fulfilled, in the absence of IBD activity: (1) Clinical criteria for CDI[26]; (2) A positive GDH test; (3) A positive culture; and (4) A positive toxin test.
In both groups, the baseline frequency of CDC and CDI was calculated by dividing the number of participants with CDC or CDI by the total number of participants in each group at study entry. To estimate the incidence of CDC in the IBD group during follow-up, participants with CDC at baseline were excluded. Incident CDC cases were divided by the total person-time at risk among participants free of CDC, and the resulting rate was expressed per 100 patient-years. A Kaplan-Meier curve was constructed to illustrate time-to-event data. The same approach was used to calculate the incidence of CDI, substituting new CDC cases with new CDI cases. Baseline characteristics of participants with IBD were summarized using absolute and relative frequencies for categorical variables and medians and interquartile ranges (IQRs) for continuous variables, as appropriate.
To evaluate the association between CDC and clinical and biochemical parameters (explanatory variables) with IBD activity (outcome variable), univariate analysis was first performed. Variables with a P value ≤ 0.05 were subsequently included in a multivariate Cox proportional hazards regression model. Associations were reported as hazard ratios (HRs) with corresponding 95% confidence intervals (CIs), and statistical significance was defined as P ≤ 0.05. A similar analytical approach was applied to assess factors associated with CDC, in which CDC was considered the outcome variable. Statistical analyses were performed using STATA version 12 (StataCorp, College Station, TX, United States). Missing data were not imputed.
A total of 250 patients with IBD were eligible in our clinic. After excluding those without active follow-up, those who did not wish to participate, and those who were otherwise unable to participate, 104 were included. After further exclusion of 3 patients owing to IBD activity at baseline, 101 participants were included in the final analysis. The flowchart is shown in Figure 1. Baseline sociodemographic and clinical characteristics of participants with IBD are summarized in Table 1.
| Variable | |
| Female | 60 (59.4) |
| Age in years | 49 (35-59) |
| Residency | |
| Mexico City | 45 (44.6) |
| State of Mexico | 17 (16.8) |
| State of Hidalgo | 10 (9.9) |
| Education level | |
| Illiterate | 1 (1.0) |
| Basic1 | 31 (30.7) |
| Intermediate2 | 22 (21.8) |
| Higher3 | 47 (46.5) |
| Smoking index | 0 (0-0.75) |
| Previous CDI | 9/98 (9.2) |
| Previous hospitalization4 | 9 (8.9) |
| Previous healthcare utilization4 | 23 (22.8) |
| Previous antibiotic use4 | 34/99 (34.3) |
| Previous statin use4 | 12 (11.9) |
| Proton pump inhibitor use4 | 39 (38.6) |
| Previous bowel surgery | 31 (30.7) |
| Age at diagnosis of IBD in years | 35 (26-50) |
| Disease duration at inclusion in years | 9 (4-16) |
| Type of IBD | |
| Ulcerative colitis | 78 (77.2) |
| Crohn’s disease | 22 (21.8) |
| Indeterminate colitis | 1 (1.0) |
| Extent of ulcerative colitis, n = 78 | |
| Proctitis | 11 (10.9) |
| Left-sided colitis | 19 (18.8) |
| Pancolitis | 48 (47.5) |
| Days without IBD activity before follow-up | 936 (238-1088) |
| Severity of last flare-up | |
| Mild | 23/60 (38.3) |
| Moderate | 32/60 (53.3) |
| Severe (uncomplicated) | 5/60 (8.4) |
| Treatment at baseline (not mutually exclusive) | |
| Sulfasalazine or mesalamine | 73/99 (73.7) |
| Corticosteroids | 34/99 (34.3) |
| Azathioprine | 32/99 (32.3) |
| Infliximab | 3/99 (3.0) |
| Methotrexate | 2/99 (2.0) |
| Laboratory parameters at baseline | |
| Hb in g/L | 145 (127-153) |
| Platelet count as × 103/μL | 275 (232-344) |
| Leukocyte count as × 103/μL | 6.7 (5.2-8.5) |
| Lymphocyte count as × 103/μL | 1.7 (1.2-2.7) |
| Serum creatinine in mg/L | 8 (6-9) |
| Blood urea nitrogen in mg/L | 144 (116-177) |
| C-reactive protein in mg/L | 4 (3-9) |
| Fecal calprotectin in pg/g | 278 (77.5-660) |
| Erythrocyte sedimentation rate in mm/hour | 8 (4-15) |
| Baseline CDC frequency | 14/101 (13.9) |
| Baseline CDI frequency | 2/101 (2.0) |
At study inclusion, CDC was identified in 14 participants with IBD (13.9%), and CDI in 2 (2.0%). The median follow-up duration for the entire IBD cohort was 420 days (IQR: 243-511), with a total of 35477 person-days of follow-up. Fifteen participants did not complete the final evaluation. After excluding these 15 participants, 86 remained at risk for incident CDC/CDI. Of these, 61 (70.9%) remained in clinical remission during the study period. During follow-up, 8 participants developed CDC (incidence rate: 8.2 events per 100 person-years) and 2 developed CDI (incidence rate: 2.1 events per 100 person-years). None of the participants with CDC at baseline or during follow-up subsequently developed CDI. Figure 2 illustrates the cumulative proportion of participants remaining free of CDC over time.
Outcome data were missing for 5 participants; therefore, 96 participants were included in this analysis. The results of this bivariate analysis are shown in Table 2. No association was observed between CDC and IBD activity. In multivariate analysis, only prior healthcare utilization remained statistically associated with IBD activity (HR = 3.48, 95%CI: 1.26-9.57, P = 0.016).
| Variable | IBD activity at any time, n = 26 | IBD remission at any time, n = 70 |
| Female | 19 (73.1) | 39 (55.7) |
| Age in years | 37 (29-57)a | 52 (42-59)a |
| Residency | ||
| Mexico City | 14 (53.8) | 29 (41.4) |
| State of Mexico | 5 (19.2) | 12 (17.1) |
| State of Hidalgo | 1 (3.9) | 9 (12.9) |
| Other state | 6 (23.1) | 20 (28.6) |
| Education level | ||
| Illiterate | 0 (0) | 1 (1.5) |
| Basic1 | 8 (30.8) | 22 (31.4) |
| Intermediate2 | 7 (26.9) | 15 (21.4) |
| Higher3 | 11 (42.3) | 32 (45.7) |
| Smoking index | 0 (0-1) | 0 (0-1) |
| Previous CDI | 1/25 (4.0) | 8/68 (11.8) |
| Previous hospitalization4 | 4 (15.4) | 5 (7.1) |
| Previous healthcare utilization4 | 10 (38.5)a | 13/70 (18.6)a |
| Previous antibiotic use4 | 12/24 (50.0) | 22 (31.4) |
| Previous statin use4 | 0 (0)a | 12 (17.1)a |
| Proton pump inhibitor use4 | 10 (38.5) | 29 (41.4) |
| Previous bowel surgery | 5 (18.5) | 23 (32.9) |
| Age at diagnosis of IBD in years | 30 (24-47) | 38 (30-51) |
| Disease duration at inclusion in years | 7 (4-13) | 10 (5-17) |
| Type of IBD | ||
| Ulcerative colitis | 21 (80.8) | 53 (75.7) |
| Crohn’s disease | 5 (19.2) | 16 (22.9) |
| Indeterminate | 0 (0) | 1 (1.4) |
| Extent of ulcerative colitis | ||
| Proctitis | 2/21 (9.5) | 8/53 (15.1) |
| Left-sided colitis | 7/21 (33.3) | 12/53 (22.6) |
| Pancolitis | 12/21 (57.2) | 33/53 (62.3) |
| Days without IBD activity before follow-up | 597 (87-1086) | 1070 (285-1087) |
| Severity of last flare-up | ||
| Mild | 6/18 (33.3) | 17/39 (43.6) |
| Moderate | 11/18 (61.1) | 18/39 (46.2) |
| Severe (uncomplicated) | 1/18 (5.6) | 4/39 (10.2) |
| Treatment at baseline (not mutually exclusive) | ||
| Sulfasalazine and mesalamine | 20/25 (80.0) | 50/69 (72.5) |
| Steroids | 13/25 (52.0) | 19/69 (27.5) |
| Azathioprine | 9/25 (36.0) | 22/69 (31.9) |
| Infliximab | 1/25 (4.0) | 2/69 (2.9) |
| Methotrexate | 1/25 (4.0) | 1/69 (1.4) |
| Laboratory parameters at baseline | ||
| Hb in g/L | 142 (127-152) | 146 (129-153) |
| Platelet count as × 103/μL | 309 (230-344) | 271 (228.3-336.3) |
| Leukocyte count as × 103/μL | 7.5 (6.1-8.6) | 6.6 (4.8-8.2) |
| Lymphocyte count as × 103/μL | 2.0 (1.2-2.6) | 1.7 (1.3-2.6) |
| Serum creatinine in mg/L | 7 (7-8) | 8 (6-9) |
| Blood urea nitrogen in mg/L | 143 (127-179) | 149 (120-176) |
| C-reactive protein in mg/L | 4 (1-7) | 4 (2-10) |
| Fecal calprotectin in pg/g | 268 (111.0-685.1) | 294.5 (61.5-674.5) |
| Erythrocyte sedimentation rate in mm/hour | 6 (3.5-11.2) | 9 (4-16.3) |
| Total CDC episodes | 4 (15.4) | 19 (27.1)5 |
| Total CDI episodes | 1 (3.8) | 3 (4.3) |
Age at IBD diagnosis was the only variable associated with CDC in both bivariate and multivariate analyses (HR = 0.91, 95%CI: 0.86-0.97, P = 0.003). Other variables showed a trend toward association with CDC, including longer disease duration at study inclusion (14 years vs 9 years in participants with and without CDC, respectively; P = 0.083) and differences in the treatment of IBD at baseline (P = 0.080). Specifically, a higher proportion of participants with CDC were receiving corticosteroids (42.9% vs 32.4%) and monoclonal antibodies (9.5% vs 0%) compared with those without CDC.
A total of 45 stool samples (one from each participant) were collected from healthy blood donors without IBD. Among these participants, 31.1% were women, the median age was 35 years (IQR: 28-47), 62.2% lived in Mexico City, and 64.4% had attained a college degree. Importantly, 28.9% and 22.2% had used antibiotics and proton pump inhibitors, resp
This study did not identify an association between CDC and IBD activity in a cohort of outpatients with IBD after a median follow-up of 420 days. Prior healthcare utilization was associated with IBD activity, possibly reflecting a more complex disease course. The frequency of CDC observed in participants with IBD was similar to that reported elsewhere and was not associated with future CDI episodes over a follow-up period longer than that studied previously.
Although some studies have reported an association between CDI and a higher risk of relapse in patients with IBD, efforts to demonstrate a similar association with CDC instead of CDI have been scarce and unsuccessful. This may be due to the elusive nature of CDC, which can occur intermittently in a substantial proportion of individuals[29]. Establishing whether IBD activity is related to underlying CDC is of considerable clinical importance for two reasons. First, it would inform the need for repeated and potentially more intensive testing in search of CDC. Second, if such an association was confirmed, treatment of CDC would be justified to avoid IBD flares and possibly CDI episodes, an approach not sup
Our study found that participants with IBD and CDC infrequently progressed to CDI during a median follow-up of 420 days. This agrees with the notion that the clinical significance of polymerase chain reaction-positive but toxin-negative tests for C. difficile in patients with IBD remains uncertain[16]. The natural history of CDC in patients with IBD remains to be fully elucidated. In this context, a recent study in the United States reported that approximately 10% of hospitalized patients without IBD were asymptomatic carriers of C. difficile at a given time point, yet only 13.4% subsequently developed CDI within 3 months; notably, most CDI cases occurred in patients who were not previously identified as carriers[29]. Although this finding is consistent with our results, the possibility that actual CDI episodes were overlooked, either owing to clinical confounding with IBD flares, insufficient testing frequency, or both, cannot be ruled out in our study.
Consistent with the findings of Singh et al[8], who reported a higher proportion of CDI episodes in younger patients with IBD, the present study found an association between younger age at diagnosis of IBD and CDC. Although little is known regarding CDC in patients with IBD, the previously aforementioned relationship could be related to the fact that IBD tends to have a more aggressive and extensive disease phenotype in younger individuals, which could predispose to CDC. Another likely explanation for this finding is the higher likelihood of colonization with toxigenic C. difficile strains in patients with shorter disease duration, as previously demonstrated[11]. However, this contrasts with the well-esta
This study has several limitations. First, the relatively small sample size resulted in limited statistical power (22%) to detect true associations between CDC and IBD flares. Second, although repeated testing was performed to identify CDC, some cases may have been missed owing to its unpredictable nature and the possibility of false-negative results. Third, the presence of CDC preceding an IBD flare does not necessarily imply a causal relationship. Fourth, comparisons between patients with IBD and healthy controls were limited by differences in testing conditions (i.e., a single stool sample from healthy volunteers) and the absence of follow-up in the latter group. Despite these limitations, our findings are consistent with previously reported data.
The strengths of this study include its prospective design with an extended follow-up period and the inclusion of patients with IBD in both clinical and biochemical remission at baseline. However, the generalizability of these findings to other settings should be done with caution, given potential differences in testing protocols and patient characteristics.
This study did not identify an association between CDC and IBD activity. Prior healthcare utilization was associated with IBD activity. Younger age at IBD diagnosis was associated with CDC. CDC was not associated with subsequent CDI in participants with IBD. Additionally, the prevalence of CDC was higher in participants with IBD than in healthy indi
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