title: Clostridium Difficile Infection in Ulcerative Colitis: Can Alteration of the Gut-associated Microbiome Contribute to Pouch Failure?
abstract: BACKGROUND
  Ulcerative colitis is frequently treated with total proctocolectomy and ileal pouch-anal anastomosis reconstruction. Causes of pouch failure and criteria for improved patient selection remain poorly understood. We aimed to identify risk factors for pouch failure.
  
  
  METHODS
  We performed a retrospective chart review of patients in a prospectively maintained database. Consecutive patients undergoing ileal pouch-anal anastomosis for inflammatory bowel disease between 2000 and 2010 at our institution were included. The primary outcome was pouch failure, defined as permanent ostomy diversion or pouch excision.
  
  
  RESULTS
  Of 417 total patients, 28 (6.7%) patients developed pouch failure. Pouch failure was associated with female gender, anastomotic leak, Crohn's disease of the pouch and preoperative Clostridium difficile colitis. The use of anti-tumor necrosis factor alpha biologics was not associated with pouch failure. Notably, 14.9% of patients were diagnosed with preoperative C. difficile colitis, a factor independently associated with pouch failure (hazard ratio 3.02; 95% confidence interval, 1.23-7.44; P = 0.016). C. difficile colitis did not contribute to failure by increasing the incidence of anastomotic leak but was associated with a diagnosis of Crohn's disease of the pouch (adjusted hazard ratio 2.27 [1.08-4.79]; P = 0.031). Anastomotic leak (P < 0.001) and pelvic abscess requiring drainage (P = 0.031) were other independent risk factors for pouch failure.
  
  
  CONCLUSIONS
  In addition to previously known risk factors, history of preoperative C. difficile colitis was associated with pouch failure after reconstruction, suggesting the need for further study into the role of the gut-associated microbiome in pouch outcomes.
authors.affiliation: *Department of Surgery, The University of Chicago Medicine, Chicago, Illinois; †Center for Biomedical Research Informatics, NorthShore University HealthSystem, Evanston, Illinois; ‡Inflammatory Bowel Disease Center, The University of Chicago Medicine, Chicago, Illinois; §Section of Colon and Rectal Surgery, Department of Surgery, The University of Chicago Medicine, Chicago, Illinois; and ‖Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, The University of Chicago Medicine, Chicago, Illinois.
authors.forename: Kinga B
authors.initials: KB
authors.lastname: Skowron
authors.forename: Brittany
authors.initials: B
authors.lastname: Lapin
authors.forename: Michele
authors.initials: M
authors.lastname: Rubin
authors.forename: Roger D
authors.initials: RD
authors.lastname: Hurst
authors.forename: David T
authors.initials: DT
authors.lastname: Rubin
authors.forename: Neil H
authors.initials: NH
authors.lastname: Hyman
authors.forename: Konstantin
authors.initials: K
authors.lastname: Umanskiy
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002641:Chicago / Q000453:epidemiology; D016360:Clostridioides difficile / Q000472:pathogenicity*; D003015:Clostridium Infections / Q000150:complications* / Q000453:epidemiology / Q000382:microbiology; D003093:Colitis, Ulcerative / Q000150:complications* / Q000382:microbiology; D039021:Colonic Pouches / Q000009:adverse effects* / Q000382:microbiology / Q000473:pathology; D005260:Female; D005500:Follow-Up Studies; D041981:Gastrointestinal Tract / Q000382:microbiology*; D006801:Humans; D008297:Male; D064307:Microbiota; D008875:Middle Aged; D015995:Prevalence; D016737:Proctocolectomy, Restorative / Q000009:adverse effects*; D011379:Prognosis; D011446:Prospective Studies; D012189:Retrospective Studies; D055815:Young Adult