Study Recommends Vancomycin as First-Line Treatment for Patients with C. Diff Infection and Inflammatory Bowel Disease

Vancomycin-containing regimens are effective first-line therapies for Clostridium difficile (C. diff) infection (CDI) in patients with inflammatory bowel disease (IBD), according to a study published in the World Journal of Gastroenterology. Further, while there is ambiguity surrounding the treatment of IBD flare in patients with CDI, case reports suggest corticosteroid initiation after appropriate antibiotic therapy may be effective.

IBD is comprised of Crohn disease (CD) and ulcerative colitis (UC), which are chronic, idiopathic inflammatory gastrointestinal disorders. The pathogenesis of IBD is not completely understood, but it’s thought to arise from interactions between environmental and host factors. C. diff, a gram-positive spore-forming anaerobe, is highly transmissible through the fecal-oral route. Its exotoxins cause a spectrum of disease ranging from mild or moderate diarrhea to fulminant infectious colitis occasionally complicated by toxic megacolon, colonic perforation, sepsis, and death.

The current study reviewed existing data from 70 articles, including a total of 932,141 patients with IBD or IBD-related hospitalizations. CDI negatively impacts short and long-term IBD-related outcomes, including rates of colectomy, escalation in IBD therapy, and mortality. It also results in longer hospitalizations, increased readmission rates, and increased in-hospital expenditures. However, despite its impact on outcome and management, many patients with newly diagnosed IBD or flaring IBD are not tested for CDI. The overlap in symptomatology between CDI and isolated IBD flare complicates the diagnosis of CDI in IBD patients, with CDI and acute inflammatory colitis being clinically indistinguishable. A diagnosis relies primarily on laboratory findings and, to a lesser degree, endoscopic or histologic findings, according to the researchers.

Guidelines outlining the approach to eradication of C. diff via antibiotic therapy or fecal microbiota transplant in the setting of recurrent CDI also include recommendations for the IBD population. IBD outpatients with non-severe CDI can be initially treated with metronidazole, however IBD inpatients regardless of disease severity should receive a vancomycin-containing regimen as first-line therapy, based on the data reviewed by the study.

According to the study, while the treatment of isolated CDI is well-studied, the initiation, maintenance, or escalation of corticosteroid, immunomodulator, or biologic therapy in IBD patients with CDI are not delineated and rely heavily on expert opinion. Results for the use of corticosteroids have been scarce and inconsistent, resulting in the American Gastroenterological Society practice guidelines suggesting postponing the escalation of steroids in the setting of acute CDI until 72 to 96 hours after the initiation of appropriate antibiotic therapy, but providing no further guidance on when to withhold, continue, or escalate corticosteroid therapy. The usage of immunomodulators is similarly lacking in data, and guidelines for the management of opportunistic infections in IBD make no explicit recommendations relating to immunomodulators for that reason. However, the investigators found that the initiation of corticosteroids in IBD flares in the context of acute CDI seems to be safe, despite a lack of research, and initiation or resumption of immunosuppressive therapy within 48 to 72 hours of targeted antibiotic therapy may be appropriate.

The study authors note that prospective studies evaluating the initiation and maintenance of IBD therapeutics in patients with CDI are necessary to help guide practice in the future.

REFERENCE

Julie D’Aoust, Robert Battat, and Talat Bessissow. Management of inflammatory bowel disease with Clostridium difficile infection. World J Gastroenterol. 2017 Jul 21; 23(27): 4986–5003. doi: 10.3748/wjg.v23.i27.4986