Monika Fischer, MD, on IBD With C Diff: How Best to Treat?

Inflammatory bowel disease (IBD) is a “magnet” for Clostridioides difficile (CDI), Monika Fischer, MD, told the audience at the virtual regional meeting of Advances in Inflammatory Disease on April 30.

“Individuals with IBD are at 5-fold risk of getting CDI, more likely to have community-onset CDI, younger at the time of CDI diagnosis, and more likely to have recurrent CDI,” she said. For these reasons, she recommends CDI testing for patients with IBD patients who present with acute flare associated with diarrhea.

Dr Fischer is an associate professor of medicine and gastroenterologist at Indiana University School of Medicine in Indianapolis, Indiana.

Patients with IBD who are at particularly high risk of contracting this disease include those who have had exposure to corticosteroids, infliximab, or adalimumab; those who have been hospitalized or had more frequent visits for outpatient care; patients with a shorter duration of IBD; and those with more comorbidities. Risks appear to be similar among patients with Crohn disease (CD) and ulcerative colitis (UC), she said.

“Testing is recommended in any patient with an acute onset of or worsening IBD,” Dr Fischer said. A 2-step testing algorithm with PCR1/toxin 2 or GDH1/toxin2 is the most reliable method of determining CDI. “PCR-only testing methods may not be helpful,” she stated.

Dr Fischer explained that the American College of Gastroenterology (ACG), the Infectious Diseases Society of America (IDSA)/Society for Healthcare Epidemiology of America (SHEA), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) all updated their treatment guidelines for treatment of CDI during the past year.

The IDSA and ESCMID guidelines, in contrast to the previous guidance, emphasizes determining a treatment strategy based on the risk of recurrence. These organizations also no longer recommend metronidazole for treatment of CDI if fidaxomicin or vancomycin are available. Fidaxomicin is considered the preferred treatment for initial cases of CDI and the first recurrence, while fecal microbiotal transplantation (FMT) or bezlotoxumab are preferred for treating any recurrence after the first, along with standard of care antibiotics.

The updated ACG guideline also recommends vancomycin or fidoxamicin as the preferred treatment for initial CDI cases, while IDSA and ESCMID state a preference for fidaxomicin over vancomycin in initial cases. Beztotoxumab is recommended for preventing recurrence of CDI “in those at high risk of recurrence,” which includes patients over the age of 65, those with health care-associated infection, hospitalization within the previous 3 months, and patients who take concomitant antibiotics or proton pump inhibitors and who have had CDI previously.

ACG recommends at least a 14-day course of vancomycin 125 mg by mouth 4 times per day for an initial episode of CDI. All 3 guidelines recommend a taper-pulse course of antibiotics for CDI recurrence, with ACG suggesting either fidaxomicin or vancomycin while IDSA and ESCMID prefer fidaxomicin over vancomycin.

In cases of multiple recurrent CDI, all the guidelines also recommend FMT over antibiotic regimens, Dr Fischer pointed out.

A recent addition to the tools to treat recurrent CDI is bezlotoxumab, an IgG monoclonal antibody to toxin B. A post-hoc analysis and a clinical trial both showed that this therapy reduces the rate of recurrent CDI by 10% to 11%. Bezlotoxumab is recommended for preventing recurrent CDI among high-risk patients, but it must be administered with caution to patients with cardiovascular comorbidities, Dr Fischer stated.

She also noted that there is some continuing debate about whether to withhold continued immunosuppression for patients with IBD during treatment for CDI. “Immunosuppressive therapy may weaken the defense mechanisms against CDI and hinder elimination of the infection,” she said, “but it is crucial for the treatment of IBD-drive inflammation.” That inflammation must be eliminated to enable the cure and prevention of recurrent CDI.

New data supports this approach. A multicenter study of 294 hospitalized patients found that immunomodulators, systemic corticosteroids, or antitumor necrosis factor agents were not associated with adverse outcomes, while serum albumin under 3 g/dL is an independent predictor of surgery and death.

For this reason, the 2021 ACG Guideline states, “Immunosuppressive IBD therapy should not be held during anti-CDI therapy in the setting of disease flare, and escalation of therapy may be considered if there is no symptomatic improvement with treatment of CDI.”

—Rebecca Mashaw

Reference:
Fischer, M. IBD with C. diff: how best to treat? Presented at: Advances in Inflammatory Bowel Disease regional meeting. April 30, 2022. Virtual.