Patients with IBD at Higher Risk of Meningitis
Key findings
- Data from a national insurance claims database were used to compare the incidence of meningitis in 109,859 patients with inflammatory bowel disease (IBD; 50,029 with Crohn's disease [CD], 59,830 with ulcerative colitis [UC]), and 296,801 without IBD
- Compared with a matched non-IBD cohort, patients with CD had a 2.17 times higher incidence of meningitis associated with a hospitalization or emergency department visit, and patients with UC had a 1.63 times higher incidence
- In a nested case–control study of IBD patients with and without meningitis, treatment with an oral 5-aminosalicylate was associated with 60% lower odds of meningitis whereas having one or more comorbidities was associated with a doubling of the odds
- A sensitivity analysis did not show a significantly increased risk of meningitis associated with any class of immunosuppressive medication
- Gastroenterologists should discuss pneumococcal and meningococcal vaccinations with their patients who have IBD, especially when they are serving as a patient's primary care physician
Inflammatory bowel diseases (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), are associated with an increased risk of infection. For bacterial meningitis, two inactivated vaccines are available, but limited evidence is available to inform vaccination guidelines.
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Bharati Kochar, MD, MSCR, a gastroenterologist in the Division of Gastroenterology at Massachusetts General Hospital, and colleagues recently conducted the first study to estimate the incidence of meningitis in U.S. adults with IBD. In the Journal of Clinical Gastroenterology, they report increased risk in IBD patients, factors that influence risk and implications for vaccination.
Study Methods
The researchers examined a nationally representative insurance database for claims made between January 2001 and June 2016. Eligible patients were 18–64 years old at the time of the first IBD claim. Two analyses were performed:
- A retrospective cohort study compared the incidence of meningitis in 109,859 patients with IBD (50,029 with CD, 59,830 with UC) and 296,801 without IBD
- A nested case–control study of risk factors compared the 162 IBD patients who developed meningitis with 281 matched controls who had IBD but no diagnosis of meningitis. Matching was done on sex, age, index IBD year, enrollment year and disease (CD or UC)
Incidence of Meningitis
A claim for meningitis associated with an emergency department visit or hospitalization was associated with an incidence-rate ratio of:
- 2.17 (95% CI, 1.69–2.78) for CD patients compared with the non-IBD cohort
- 1.63 (95% CI, 1.26–2.11) for UC patients compared with the non-IBD cohort
Patients 18 to 29 years old had numerically higher rates of meningitis than older age groups.
In the IBD cohort, 25% of meningitis cases were coded as "bacterial meningitis," 50% as "viral meningitis" and the remainder as "other."
Risk Factors and Protective Factors
On multivariable analysis, the odds of meningitis in IBD patients were significantly:
- Higher in those with a Charlson comorbidity index ≥1 (OR, 2.21)
- Lower in those who lived in the Midwest or West than in the East (OR, 0.68 and 0.64, respectively)
- Lower in those treated for ≥2 weeks with an oral 5-aminosalicylate (OR, 0.40)
Sensitivity analysis did not show a significantly increased risk of meningitis associated with any class of immunosuppressant medication.
Implications for Vaccination
The leading causes of bacterial meningitis in the U.S. are Streptococcus pneumoniae, which is associated with a 30% mortality rate, and Neisseria meningitidis. The American College of Gastroenterology already recommends pneumococcal vaccination for all CD patients and for UC patients on immunosuppressive medication.
This study reinforces the importance of discussing those guidelines with patients, along with meningococcal vaccination for young adults with IBD, who are at particularly high risk of bacterial meningitis. These discussions are especially important when the gastroenterologist is serving as the primary care physician for a patient with IBD.
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