Practice of gastroenterologists in treating flaring inflammatory bowel disease patients with clostridium difficile

Yanai, Henit; Nguyen, Geoffrey C.; Yun, Laura; Lebwohl, Oscar; Navaneethan, Udayakumar; Stone, Christian D.; Ghazi, Leyla; Martin, Paul; Brooks, Jeffrey L.; Bernstein, Çharles N.; Ben‐Horin, Shomron

doi:10.1002/ibd.21514

Cited by 74 publications

(26 citation statements)

References 25 publications

(29 reference statements)

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“…In the setting of suspected IBD flare in a patient with known CDI, concurrent corticosteroid therapy is reasonable and supported by expert opinion[3,71]. Nevertheless, significant uncertainty exists among practitioners with regards to the initiation of corticosteroid therapy and its safety in the context of an ongoing CDI-mediated colitis.…”

Section: Discussionmentioning

confidence: 99%

“…Nevertheless, significant uncertainty exists among practitioners with regards to the initiation of corticosteroid therapy and its safety in the context of an ongoing CDI-mediated colitis. A survey of 169 North American gastroenterologists demonstrated divergence among clinicians with regards to initiating therapy in hospitalized UC patients with CDI; 54% opted for antibiotic monotherapy compared to 46% opting for a combination of antibiotics with either azathioprine or corticosteroids[71]. This concern originates from findings of several observational studies, detailed above, demonstrating increased risk of CDI, rCDI, and worse outcomes among IBD patients receiving corticosteroids[44,49,70].…”

Section: Discussionmentioning

confidence: 99%

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Management of inflammatory bowel disease withClostridium difficileinfection

D’Aoust

Battat

Bessissow

2017

WJG

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AIMTo address the management of Clostridium difficile (C. difficile) infection (CDI) in the setting of suspected inflammatory bowel disease (IBD)-flare.METHODSA systematic search of the Ovid MEDLINE and EMBASE databases by independent reviewers identified 70 articles including a total of 932141 IBD patients or IBD-related hospitalizations.RESULTSIn those with IBD, CDI is associated with increased morbidity, including subsequent escalation in IBD medical therapy, urgent colectomy and increased hospitalization, as well as excess mortality. Vancomycin-containing regimens are effective first-line therapies for CDI in IBD inpatients. No prospective data exists with regards to the safety or efficacy of initiating or maintaining corticosteroid, immunomodulator, or biologic therapy to treat IBD in the setting of CDI. Corticosteroid use is a risk factor for the development of CDI, while immunomodulators and biologics are not.CONCLUSIONStrong recommendations regarding when to initiate IBD specific therapy in those with CDI are precluded by a lack of evidence. However, based on expert opinion and observational data, initiation or resumption of immunosuppressive therapy after 48-72 h of targeted antibiotic treatment for CDI may be considered.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Management of inflammatory bowel disease withClostridium difficileinfection

D’Aoust

Battat

Bessissow

2017

WJG

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“…The questionnaire was distributed by sub-investigators to respondents directly or through an additional contact (one-stage “Snow-balling” technique). We deliberately elected to distribute questionnaires directly, as this technique was previously found to result in a higher response rate[4], as opposed to low response rates often experienced by surveys conducted through mailing lists of professional societies’ members or through survey websites[5,6]. The study was approved by the Sheba Medical Center Institutional Review Board.…”

Section: Methodsmentioning

confidence: 99%

“…Comparisons of proportions were performed by Z test when single population was considered or by Fisher exact test when comparing proportions between two populations ( e.g ., responses of IBD experts versus non-experts). In the absence of definitive definition of what constitutes an IBD expert and in line with previous studies[4], respondents with ≥ 25% of their patients being IBD patients were pragmatically defined as IBD experts.…”

Section: Methodsmentioning

confidence: 99%

Combination of corticosteroids and 5-aminosalicylates or corticosteroids alone for patients with moderate-severe active ulcerative colitis: A global survey of physicians' practice

Ben‐Horin¹,

Andrews²,

Κατσάνος³

et al. 2017

WJG

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AIMTo examine treatment decisions of gastroenterologists regarding the choice of prescribing 5-aminosalycilates (5ASA) with corticosteroids (CS) versus corticosteroids alone for patients with active ulcerative colitis (UC).METHODSA cross-sectional questionnaire exploring physicians’ attitude toward 5ASA + CS combination therapy vs CS alone was developed and validated. The questionnaire was distributed to gastroenterology experts in twelve countries in five continents. Respondents’ agreement with stated treatment choices were assessed by standardized Likert scale. Background professional characteristics of respondents were analyzed for correlation with responses.RESULTSSix hundred and sixty-four questionnaires were distributed and 349 received (52.6% response rate). Of 340 eligible respondents, 221 (65%) would continue 5ASA in a patient hospitalized for intravenous CS treatment due to a moderate-severe UC flare, while 108 (32%) would stop the 5ASA (P < 0.001), and 11 (3%) are undecided. Similarly, 62% would continue 5ASA in an out-patient starting oral CS. However, only 140/340 (41%) would proactively start 5ASA in a hospitalized patient not receiving 5ASA before admission. Most (94%) physicians consider the safety profile of 5ASA as very good. Only 52% consider them inexpensive, 35% perceive them to be expensive and 12% are undecided. On multi-variable analysis, less years of practice and perception of a plausible additive mechanistic effect of 5ASA + CS were positively associated with the decision to continue 5ASA with CS.CONCLUSIONDespite the absence of data supporting its benefit, most gastroenterologists endorse combination of 5ASA + CS for patients with active moderate-to-severe UC. Randomized controlled trials are needed to assess if 5ASA confer any benefit for these patients.

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“…A survey of American and Canadian gastroenterologists on the topic found them split on the issue, with 46% electing to use antibiotics alone to treat the CDI and 54% electing to use both antibiotics and immunomodulators together (60). One might speculate that “hedging your bets” and treating for both conditions would be the safest approach, however a retrospective, multicenter study in Europe noted an increased risk of mortality in patients treated with both antibiotics and immunomodulators (defined as prednisone >20 mg/day, azathioprine, 6-mercaptopurine, methotrexate, biologics, cyclosporine, or tacrolimus)(61).…”

Section: Treatment Of CDI Ibd or Both?mentioning

confidence: 99%

Epidemiology, Diagnosis, and Management of Clostridium difficile Infection in Patients with Inflammatory Bowel Disease

Rao

Higgins

2016

Inflammatory Bowel Diseases

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Clostridium difficile infection (CDI) is a major source of morbidity and mortality for the US healthcare system, and frequently complicates the course of inflammatory bowel disease (IBD). Patients with IBD are more likely to be colonized with C. difficile and develop active infection than the general population. They are also more likely to have severe CDI and develop subsequent complications such as IBD flare, colectomy, or death. Even after successful initial treatment and recovery, recurrent CDI is common. Management of CDI in IBD is fraught with diagnostic and therapeutic challenges, since the clinical presentations of CDI and IBD flare have considerable overlap. Fecal microbiota transplantation can be successful in curing recurrent CDI when other treatments have failed, but may also trigger IBD flare and this warrants caution. New, experimental treatments including vaccines, monoclonal antibodies, and non-toxigenic strains of C. difficile offer promise but are not yet available for clinicians. A better understanding of the complex relationship between the gut microbiota, CDI, and IBD is needed.

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Practice of gastroenterologists in treating flaring inflammatory bowel disease patients with clostridium difficile

Abstract: There is significant disagreement among gastroenterologists on whether combination AB+IM or AB alone should be given to IBD patients with CDI-associated flares. Controlled trials are needed to investigate the optimal management approach to this clinical dilemma.

Cited by 74 publications

References 25 publications

Management of inflammatory bowel disease withClostridium difficileinfection

Management of inflammatory bowel disease withClostridium difficileinfection

Combination of corticosteroids and 5-aminosalicylates or corticosteroids alone for patients with moderate-severe active ulcerative colitis: A global survey of physicians' practice

Epidemiology, Diagnosis, and Management of Clostridium difficile Infection in Patients with Inflammatory Bowel Disease

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