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We would like to thank Drs Cong Dai, Min Jian, and Yu-Hong Huang for their reflections on our meta-analysis, where we conclude that previous antibiotic use, biologics, and colonic involvement may be risk factors for Clostridium difficile infection [CDI] in patients with inflammatory bowel disease [IBD].1

We agree that nucleic acid amplification testing [NAAT], including polymerase chain reaction [PCR], is more sensitive than enzyme immunoassay [EIA] for the diagnosis of CDI. However, given its inability to distinguish CDI from asymptomatic carriage, there is a risk of overdiagnosis of CDI when using PCR alone. Thus, the updated 2017 guidelines for CDI recommend a multistep algorithm for testing (i.e. glutamate dehydrogenase [GDH] plus enzyme-linked immunosorbent assay or enzyme immunoassay [ELISA/EIA]; GDH plus ELISA/EIA arbitrated by NAAT; or NAAT plus ELISA/EIA) as a more sensitive method for diagnosis of CDI.2 In our meta-analysis, 12 studies diagnosed CDI by stool ELISA/EIA and two studies used PCR. The remaining studies [n = 10] used administrative databases to identify CDI-positive patients. The proclivity to use ELISA/EIA alone as a diagnostic method in these studies could be explained by the recommendations put forth in the previous 2010 guidelines for CDI, which recommend stool culture as the most sensitive test. However, they recognises ELISA/EIA as a more rapid, albeit less sensitive, alternative diagnostic method.3

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