Management of Immunosuppression in the Setting of Clostridioides Difficile Infection and Inflammatory Bowel Disease
One aspect of management that clinicians may struggle with is the positioning of immunosuppression for IBD in the setting of active CDI. CDI may exacerbate underlying IBD, and therefore many patients should undergo escalation of immunosuppressive therapy. Guidance for these scenarios is mainly from expert opinion as well as retrospective studies (Table 1). In a European cohort of 155 hospitalized patients with CDI and IBD, 104 were treated with immunosuppressive medications (including corticosteroids, thiopurines, methotrexate, calcineurin inhibitors, or biologics) and antibiotics while 51 were treated with antibiotics alone. The primary composite outcome of death, colectomy, megacolon, bowel perforation, shock, or respiratory failure occurred in 12% of the combination therapy group compared with none in the antibiotic monotherapy group. On multivariate analysis, there was no significant independent association between combination therapy and the primary outcome, however there was an association between two or more immunosuppressive medications and the primary outcome. In a retrospective cohort of 294 patients with CDI and IBD, a low-serum albumin and hemoglobin and elevated creatinine were independent predictors of shorter time colectomy or death, but use of immunosuppressive medications were not. Data specific to corticosteroids are conflicting, as one retrospective study of 137 IBD patients found that escalation of corticosteroids was associated with a two-fold higher odds of colon surgery within 1 year after CDI. However, three other retrospective studies of similar size did not identify adverse outcomes associated with corticosteroid therapy.[79,81,82]
In a recent multicenter study of 207 patients with CDI and IBD, 62 patients underwent escalation to corticosteroids or biologic therapy. The adjusted odds of severe outcomes (death, sepsis, or colectomy) within 90 days were reduced among patients who underwent escalation of immunosuppression compared with those who were not escalated. In the absence of much-needed prospective data regarding this issue, the most recent American Gastroenterological Association clinical practice guidelines recommend initiation of corticosteroids or immunosuppressive therapy 3–4 days after persistent symptoms of colitis despite appropriate antimicrobial therapy for CDI. Patients should be monitored closely for progression of symptoms and other complications during this vulnerable time. A comprehensive diagnostic and management algorithm for CDI in IBD is presented in Figure 1.
Comprehensive diagnostic and management algorithm of Clostridioides difficile infection in inflammatory bowel disease. CDI, Clostridioides difficile infection; EIA, enzyme immunoassay; FMT, fecal microbiota transplant; GDH, glutamate dehydrogenase; IBD, inflammatory bowel disease; NGT, nasogastric tube; PO, oral.
Curr Opin Gastroenterol. 2021;37(4):336-343. © 2021 Lippincott Williams & Wilkins