Combination Immunomodulator and Antibiotic Treatment in Patients With Inflammatory Bowel Disease and Clostridium difficile Infection

Ben‐Horin, Shomron; Margalit, Maya; Bossuyt, Peter; Maul, Jochen; Shapira, Yami; Bojic, Daniela; Chermesh, Irit; Al‐Rifai, Ahmad; Schoepfer, Alain; Bosani, M.; Allez, Matthieu; Lakatos, László; Bossa, Fabrizio; Eser, Alexander; Stefanelli, Tommaso; Carbonnel, Franck; Κατσάνος, Κωνσταντίνος; Checchin, D.; Miera, Inés Sáenz de; Chowers, Yehuda; Moran, Gordon W

doi:10.1016/j.cgh.2009.05.031

Cited by 127 publications

(122 citation statements)

References 25 publications

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“…Th e incidence of C. diffi cile in hospitalized patients with UC is rising dramatically. Th is infection results in higher costs, longer length of stay, and increased morbidity and mortality ( 20 -22,24,252 ), and it is more refractory to treatment in patients on immunosuppressive drugs ( 253 ). A recent prospective study of hospitalized patients (without IBD) showed a high failure rate with metronidazole treatment for C. diffi cile in patients who had been recently treated with cephalosporins, in those who were positive for C. diffi cile on admission, and in those transferred from another hospital.…”

Section: The Patient With Severe Colitis Refractory To Maximal Oral Tmentioning

confidence: 99%

Ulcerative Colitis Practice Guidelines in Adults: American College of Gastroenterology, Practice Parameters Committee

Kornbluth

Sachar

2010

American Journal of Gastroenterology

1,144

977

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Guidelines for clinical practice are aimed to indicate preferred approaches to medical problems as established by scientifi cally valid research. Double-blind placebo controlled studies are preferable, but compassionate-use reports and expert review articles are used in a thorough review of the literature conducted through Medline with the National Library of Medicine. When only data that will not withstand objective scrutiny are available, a recommendation is identifi ed as a consensus of experts. Guidelines are applicable to all physicians who address the subject regardless of specialty training or interests and are aimed to indicate the preferable but not necessarily the only acceptable approach to a specifi c problem. Guidelines are intended to be fl exible and must be distinguished from standards of care, which are infl exible and rarely violated. Given the wide range of specifi cs in any healthcare problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the board of trustees. Each has been intensely reviewed and revised by the Committee, other experts in the fi eld, physicians who will use them, and specialists in the science of decision analysis. The recommendations of each guideline are therefore considered valid at the time of composition based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at publication to assure continued validity. The recommendations made are based on the level of evidence found. Grade A recommendations imply that there is consistent level 1 evidence (randomized controlled trials), grade B indicates that the evidence would be level 2 or 3, which are cohort studies or case -control studies. Grade C recommendations are based on level 4 studies, meaning case series or poor-quality cohort studies, and grade D recommendations are based on level 5 evidence, meaning expert opinion.

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Section: The Patient With Severe Colitis Refractory To Maximal Oral Tmentioning

confidence: 99%

Ulcerative Colitis Practice Guidelines in Adults: American College of Gastroenterology, Practice Parameters Committee

Kornbluth

Sachar

2010

American Journal of Gastroenterology

1,144

977

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“…In patients with severe colitis, however, particularly in the presence of additional risk factors (e.g., recent health-care contact, antibiotic use, hospitalization) concomitant treatment for presumed C. diffi cile and an IBD fl are may be warranted. Because it is oft en diffi cult to distinguish the eff ect of CDI independent from that of underlying IBD and because the data reporting worse outcomes in patients on combination immunosuppression and antibiotic therapy ( 153,154 ) have several limitations, we recommend that ongoing immunosuppression be continued at existing doses in IBD-CDI patients. One study has suggested that reducing the dose of systemic corticosteroids may help reduce the need for colectomy ( 149 ) Patients who have had a colectomy and have an ileostomy or an ileo-anal pouch remain at risk for CDI, with symptoms of increased stool frequency, or ostomy output, bleeding, or systemic features of fever, abdominal pain, and leukocytosis ( 155 -158 ).…”

Section: Management Of CDI and Co-morbid Conditionsmentioning

confidence: 99%

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Surawicz

Brandt

Binion

et al. 2013

American Journal of Gastroenterology

1,468

1,408

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Clostridium diffi cile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness and places a high burden on our health-care system. Patients with CDI typically have extended lengths-of-stay in hospitals, and CDI is a frequent cause of large hospital outbreaks of disease. This guideline provides recommendations for the diagnosis and management of patients with CDI as well as for the prevention and control of outbreaks while supplementing previously published guidelines. New molecular diagnostic stool tests will likely replace current enzyme immunoassay tests. We suggest treatment of patients be stratifi ed depending on whether they have mild-to-moderate, severe, or complicated disease. Therapy with metronidazole remains the choice for mildto-moderate disease but may not be adequate for patients with severe or complicated disease. We propose a classifi cation of disease severity to guide therapy that is useful for clinicians. We review current treatment options for patients with recurrent CDI and recommendations for the control and prevention of outbreaks of CDI. Am J Gastroenterol 2013; 108:478-498; doi: 10.1038/ajg.2013 12. In patients in whom oral antibiotics cannot reach a segment of the colon, such as with Hartman's pouch, ileostomy, or colon diversion, vancomycin therapy delivered via enema should be added to treatments above until the patient improves. (Conditional recommendation, low-quality evidence)13. The use of anti-peristaltic agents to control diarrhea from confi rmed or suspected CDI should be limited or avoided, as they may obscure symptoms and precipitate complicated disease. Use of anti-peristaltic agents in the setting of CDI must always be accompanied by medical therapy for CDI. (Strong recommendation, low-quality evidence) Management of severe and complicated CDI14. Supportive care should be delivered to all patients and includes intravenous fl uid resuscitation, electrolyte replacement, and pharmacological venous thromboembolism prophylaxis. Furthermore, in the absence of ileus or signifi cant abdominal distention, oral or enteral feeding should be continued. 17. Vancomycin delivered orally (500 mg four times per day) and per rectum (500 mg in a volume of 500 ml four times a day) plus intravenous metronidazole (500 mg three times a day) is the treatment of choice for patients with complicated CDI with ileus or toxic colon and / or signifi cant abdominal distention. (Strong recommendation, low-quality evidence)18. Surgical consult should be obtained in all patients with complicated CDI. Surgical therapy should be considered in patients with any one of the following attributed to CDI: hypotension requiring vasopressor therapy; clinical signs of sepsis and organ dysfunction (renal and pulmonary); mental status changes; white blood cell count ≥ 50,000 cells / μ l, lactate ≥ 5 mmol / l; or failure to improve on medical therapy after 5 days. (Strong recommendation, moderate-quality evidence) Management of recurrent CDI (RCDI)19. The fi rst recurrence of CDI can be treated ...

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“…Increased colectomy rates in IBD patients with CDI have also been reported by other studies (9,12,26). However, other studies found no significant differences in colectomy risk between IBD patients with CDI and those without CDI (10,30,35,41). A four-fold higher mortality rate in hospitalized patients with concurrent IBD and CDI as compared to those with IBD alone was reported by two USA studies using NIS data (12,46), while another study from United Kingdom (9), analyzing nationwide data, found that IBD patients with CDI were approximately six times more likely to die in hospital than those admitted for IBD alone, contrasting reports from single-center studies which found a similar or a non-significant increase in the relative mortality risk in IBD patients co-infected with C. difficile compared with uninfected IBD patients (10,26).…”

Section: Discussionmentioning

confidence: 55%

“…Laboratory findings in CDI and IBD flares are also similar (leukocytosis, anemia, hypoalbuminemia). Moreover, at colonoscopy pseudomembranes are often absent in IBD patients with CDI (41).…”

Section: Clinical Featuresmentioning

confidence: 99%

“…A retrospective multicenter study has demonstrated that IBD patients with CDI treated with a combination of antibiotics and maintenance or newly added immunomodulatory drugs were more likely to have severe outcomes (colectomy, mortality) than those treated only with antibiotic (41). However, there is a significant disagreement among gastroenterologists on whether antibiotics alone or combined antibiotics/immunomodulators should be administered in IBD patients presenting with flares and CDI.…”

Section: Medical Treatment (Table 2) Antibioticsmentioning

confidence: 99%

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Clostridium difficile infection and inflammatory bowel disease

Cojocariu

Stanciu

Stoica³

et al. 2020

Turk J Gastroenterol

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Over the past 15 years, Clostridium difficile infection (CDI) in patients with inflammatory bowel disease (IBD) has increased both in incidence and severity. Traditional risk factors for CDI are similar in IBD and non-IBD populations, but there is a significant proportion of IBD patients which have distinctive characteristics. Patients with ulcerative colitis (UC) are more susceptible to CDI and have more severe outcomes than those with Crohn's disease (CD). CDI may be difficult to distinguish from an IBD flare due to similar clinical presentation, and therefore screening for CDI is recommended at every flare in such patients. Several studies showed worse clinical outcomes in IBD patients with CDI, including longer hospital stay, higher colectomy and mortality rates than in those without CDI. Vancomycin and metronidazole appear to have similar efficacy in patients with moderate disease, but vancomycin is preferred in severe disease. Measures must be taken to prevent the spread of infection. Clinicians should have a high index of suspicion for CDI when evaluating a patient with IBD flare, as rapid detection and prompt treatment of infection improve outcomes. This review summarizes the available literature on epidemiology, risk factors, clinical aspects, diagnostic methods, treatment, outcome, and prevention of CDI in IBD patients.

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Combination Immunomodulator and Antibiotic Treatment in Patients With Inflammatory Bowel Disease and Clostridium difficile Infection

Cited by 127 publications

References 25 publications

Ulcerative Colitis Practice Guidelines in Adults: American College of Gastroenterology, Practice Parameters Committee

Ulcerative Colitis Practice Guidelines in Adults: American College of Gastroenterology, Practice Parameters Committee

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Clostridium difficile infection and inflammatory bowel disease

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