How Does Clostridium Difficile Colitis Impact Inflammatory Bowel Disease?

Clostridium difficile (C diff) colitis is common among individuals with inflammatory bowel disease (IBD) and can be indistinguishable from IBD flares, according to a presentation by Joel Pekow, MD, at the Advances in Inflammatory Bowel Diseases Regional in Chicago, Illinois.

“In the last few decades there has been an enormous rise in the incidence of Clostridium difficile,” said Pekow, who is an assistant professor of medicine at The University of Chicago. “In addition, there has been rise in community-acquired C diff.”

Risk factors of C diff among individuals without IBD include older age, greater co-morbidity and host immunity, antibiotic use, and proton-pump inhibitor therapy, among others. Risk factors of C diff among individuals with IBD include antibiotic use in the last 30 days, colonic disease, and the use of biologics.

If a patient has C diff, morbidity is greater in IBD because there is an increased risk of colectomy long term, increased mortality, need for escalated IBD therapy, and greater hospitalization costs.

Current treatments for C diff are vancomycin and fidaxomicin. Metronidazole is not recommended as first line treatment of C diff by the American College of Gastroenterology or the Infectious Diseases Society of America, according to Pekow’s presentation.

Treatment options for individuals with refractory C diff include early surgical consultation and co-management; oral vancomycin; tigecycline; single infusion of intravenous immunoglobulin; and fecal microbiota transplant (FMT).

“For FMT, patients with refractory and severe disease usually need more than 1 fecal transplant to clear their C diff infection,” said Pekow.

Pekow noted that whether to increase immunosuppression for an individual with IBD and C diff is a frequent question. “It is recommended to avoid an increase, but in a majority of patients with IBD who are hospitalized, they need treatment for both their C diff and IBD so concurrent antibiotic and immunosuppression may be required.”

Preventing recurrent C diff is key. First, clinicians should identify and eliminate sources of reinfection and risk factors for recurrence, according to Pekow’s presentation. Other options to consider are re-treatment with the same medication, prolonged course of vancomycin; fidaxomicin; FMT; monoclonal antibodies to toxins A and B; rifaximin chaser; and Saccharomyces boulardii.

“Start to think about FMT if the patient has had 2 recurrences,” said Pekow. “[FMT] is vastly superior to recurrent antibiotic use.”

Data is limited on the safety of FMT in immunosuppressed individuals. Therefore, it is “recommended to talk to patients about risks and screen for resistant bacteria in the donor stool.”

Key take home messages from Pekow’s presentation included:

• a toxin-based or 2-step testing should be used for diagnosis of C diff;
• oral vancomycin or fidaxomicin are first line treatments; and
• treatment steps should include fidaxomicin, longer duration of vancomycin, or FMT to prevent recurrence.

—Melinda Stevens

Reference:

Pekow J. Prevention and management of clostridium difficile colitis. Presented at: Advances in Inflammatory Bowel Disease Regionals. July 20, 2019; Chicago, IL.