Challenges Remain in Treating IBD Patients with C Difficile Infections

It can be challenging and deadly to treat inflammatory bowel disease (IBD) patients who develop Clostridioides difficile infections (CDI).

A team, led by Dr. Campbell, Department of Gastroenterology, NHS Greater Glasgow and Clyde, examined recent cases to assess the practice and subsequent outcomes for IBD patients at risk of developing an C difficile infection. The data was presented during the 16th Congress of European Crohn's and Colitis Organisation (ECCO).

The Risk

IBD is a known risk factor for CDI and this patient population has higher mortality and morbidity. A prevailing thought that factors such as alterations in the gut microbiome, mucosal disruption and immunosuppression provide a synergistic environment for C difficile infections to complicate an IBD flare.

However, there is conflicting data available on this management.

The Analysis

In the retrospective analysis, the researchers examined 29 hospitalization cases of CDI in IBD patients at the Greater Glasgow and Clyde between 2017-2018. The team identified patients using a CDI database held by the microbiology department, extrapolating individuals with co-existing IBD.

Of the patients with IBD, 21 had ulcerative colitis, 7 had Crohn’s disease, and 1 individual had an unclassified diagnosis of IBD. At the time of CDI, 24 participants were on immunosuppressive therapy and 11 individuals were on dual or triple immunosuppression. The treatment continued during admission for all but 3 participants in the study.

They collected data on demographics, IBD subtype, and the presence of other known C difficlle infection risk factors and assessed the severity of symptoms using the Truelove and Witts Criteria. The team also identified initial management and changes following the diagnosis of the infection.

The investigators sought main outcomes of the length of hospital stay, survival to discharge, and the requirement for surgical intervention. They assessed 1 year outcomes by recording mortality, treatment escalation, and hospital re-admission.

Results

The researchers found once the CDI diagnosis was established, 16 individuals were treated with metronidazole and 13 patients were treated with vancomycin.

In addition, 13 patients were treated with oral steroids, 5 individuals were treated with IV steroids, and 11 participants were not treated with steroids.

Overall, there were no clear correlation between steroid management and any of the outcomes. There was a high chance of colectomy in 12 patients following an assessment with the Travis criteria on day 3. However, only 1 individual in this patient subgroup required surgical intervention.

In addition, no patients received a fecal transplant and the median length of stay was 15 days. One patient did die during their hospital admission and 6 died at the 1 year mark. The one-year mortality was 24%.

A further analysis shows 3 individuals had CDI as a contributory factor listed on the death certificate and 31% of the surviving patients had their IBD treatment escalated in the year following admission, 17% were treated for CDI relapse, and 28% had to be readmitted to the hospital.

“Managing CDI in patients with co-existing IBD is challenging,” the authors wrote. “This case series highlights the lack of consensus on how this should be approached, even within a single health board. Morbidity and mortality are high. This suggests that a wider body of work is required to establish guidelines and provide better outcomes.”

The study, “Clostridium difficile infection in pre-existing inflammatory bowel disease: Management and outcomes,” was published online by the European Crohn’s and Colitis Organisation