Gastrointestinal Infections in IBD Flares: Can PCR-Based Stool Tests Differentiate the Smoke from the Fire?
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EDITORIAL
Gastrointestinal Infections in IBD Flares: Can PCR‑Based Stool Tests Differentiate the Smoke from the Fire? Jordan E. Axelrad1 · Jenny S. Sauk2
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Gastrointestinal (GI) infections are a major cause of morbidity and mortality worldwide [1, 2]. In the past, the diagnosis of infective pathogens was accomplished via microscopic examination or culture of, or detection of coproantigens in stool samples. These methods are limited by a lengthy turnaround time, poor sensitivity, a requirement for experts in microscopy, difficulty in isolating non-bacterial agents, and the influence of preanalytical factors such as antibiotics. Using these conventional methods and owing to infrequent detection, non-Clostridioides difficile enteric infections were thought to be minor contributors to the pathogenesis and the disease course of inflammatory bowel disease (IBD) [3, 4]. While multiple studies have supported the involvement of C. difficile toward exacerbations of IBD, with a crosssectional prevalence up to 16% during an acute flare, far less is known about non-C. difficile pathogens [5]. Recently, rapid and highly sensitive stool molecular multiplex polymerase chain reaction (PCR) panel assays, or GI pathogen panels (GPPs) have replaced relatively insensitive culturedependent methods for the detection of enteric pathogens in clinical practice. GPPs enable the simultaneous qualitative detection and identification of nucleic acids from multiple bacteria, viruses, and parasites directly from stool samples in Cary Blair transport medium obtained from individuals with signs and/or symptoms of GI infection. Using this technology, there has been renewed interest in the impact of enteric pathogens on IBD pathogenesis beyond C. difficile. A few recent reports have evaluated stool multiplex PCR panels in patients with IBD [6–8]. In a cross-sectional study * Jordan E. Axelrad [email protected] 1
Inflammatory Bowel Disease Center at NYU Langone Health, Division of Gastroenterology and Hepatology, NYU School of Medicine, New York, NY, USA
UCLA Center for Inflammatory Bowel Diseases, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine At UCLA, Los Angeles, CA, USA
2
using the BioFire® FilmArray® GPP, a platform capable of detecting 22 organisms, including common pathogenic strains of bacteria, parasites, and viruses during symptomatic relapse in 214 patients with IBD, enteric infection was detected in 27% of tests with C. difficile as the most common (13%) followed by Escherichia coli subtypes (8%) and viruses (5%), largely norovirus [5]. IBD therapy escalation was less frequent in those with a positive stool test. In a follow-up analysis of 277 patients with Crohn’s disease (CD), 300 patients with ulcerative colitis (UC), and 8826 patients without IBD who underwent a BioFire® FilmArray® GPP for diarrhea, non-C. difficile enteric infection was detected in 18%, 16%, and 27% of tests in patients with CD, UC, a
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