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Pearls From: David Rubin, MD

Pearls From: David Rubin, MD

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Recent analyses have suggested that the rate of C. difficile infection in patients with inflammatory bowel disease (IBD) has increased at a significantly faster rate than in the non-IBD population, according to David Rubin, MD, of the University of Chicago. In this exclusive MedPage Today video, Rubin discusses why this might be, as well as how to best treat C. difficile once identified in a patient.

A transcript of his remarks follows:

We’re talking about Clostridium difficile infections in patients with inflammatory bowel disease. It is well-known and well-described now that Clostridium difficile has been on the rise not just in North America, but actually around the world. It has become a significant problem in many types of patients, and one of the groups that seems particularly at risk are those with chronic inflammatory bowel conditions like ulcerative colitis and Crohn’s disease.

In fact, in some recent analyses it’s been shown that the rate of C. difficile infection in IBD has been increasing quite dramatically and at a faster rate than the rising rate of C. difficile in the non-IBD population. This is of particular importance because patients who get C. diff with their IBD are more likely to require hospitalization and more likely to require surgery related to their IBD. The reasons for this are not entirely known, but we believe it’s due to the changing microbiome in the gut, which we know in patients with IBD tends to occur somewhat spontaneously and variably over time. We also note that the rate of C. diff may be rising because of some of the therapies patients are on, whether it’s an immunosuppressive therapy or whether it’s related to antibiotic exposure. It’s also possible that patients are developing more C. diff because IBD patients are seen in the hospital setting and the clinic setting, and have procedures more often than other patients. So they may be already colonized more often than other people who develop C. difficile.

Recognizing that this is a significant problem, it’s actually been identified as a quality measure for managing IBD to check for the presence of C. difficile as a potential risk factor and cause for relapses. Every patient in your practice who presents with a flare, even if you can’t identify a recent antibiotic exposure or something else, should be tested for C. difficile, and you should also recognize the different types of tests that are available.

For example, a PCR test for the organism may detect the organism when it’s not actually pathogenic, compared to the older ELISA test which look for the toxin, which is produced when the organism is thought to be more of a pathogen. Distinguishing between that is actually a challenge and we don’t have a good answer to that yet, but you should know which assay your hospital uses.

Now the second issue is after you’ve identified that a patient of yours has a C. diff infection, we need to treat it. There have been a number of small studies that have suggested that oral vancomycin is superior to metronidazole as a treatment for Clostridium difficile in general, but also in the IBD population. This is an important point because there has been recognized metronidazole resistance among C. difficile strains and that would be a problem if you can’t eradicate the organism.

For recurrent C. difficile in the setting of IBD, fecal transplantation has been studied. Although it’s shown to be effective, it’s not as effective as doing fecal transplantation in the non-IBD patient population who has had recurrent C. difficile. The data suggests that recurrent C. diff is eradicated successfully in about 75% of patients with IBD. In the general population in whom this has been studied, it’s about 90% successful. The take-home message is that fecal transplant may still be necessary to treat recurrent C. diff in an IBD patient, but the success rate may not be as good and you may in fact need to consider a second transplant.

It also comes up often that fecal transplant might treat the IBD. There are some data to suggest it may have a role as a repetitive therapy to treat ulcerative colitis, but the single treatments of fecal transplant for C. diff do not seem to appreciably treat the IBD. The answer to the question that always comes up, “Will this also fix the IBD?” is no.

The last point here is how long do you treat with the antibiotic of choice, related to whether it’s metronidazole — or as I suggested, vancomycin as a preferred antibiotic — the general guidelines don’t specifically mention IBD, and they say two weeks is the usual course of antibiotics.

We’ve recently looked at our experiences at the University of Chicago in which a number of our patients were treated for 30 days and we demonstrated statistically significantly reduced rates of recurrence with the longer duration of treatment.

My recommendation based on our own experience here and not yet published data that I’m sharing with you is to treat for a month when you have an IBD patient who develops C. difficile. The newer agents that have been developed to treat C. diff — such as fidaxomicin and the emerging vaccinations, and some antibody therapies against C. diff — have not been studied in the IBD population. Therefore, I can’t comment further on how it might work in our IBD patients, but we certainly are hopeful that these may offer new opportunities in the future. Thank you.


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