Combination immunomodulator and antibiotic treatment in patients with inflammatory bowel disease and clostridium difficile infection.
OBJECTIVE
Management of Clostridium difficile infection in patients with flaring inflammatory bowel disease (IBD) has not been optimized. We investigated the effects of combination therapy with antibiotics and immunomodulators in patients with IBD and C difficile infection.


METHODS
We analyzed data from 155 patients (59% with ulcerative colitis [UC]) from a retrospective, European Crohn's and Colitis organization, multi-center study comparing outcome of hospitalized IBD patients with C difficile infection who were treated with antibiotics (n = 51) or antibiotics and immunomodulators (n = 104). The primary composite outcome was death or colectomy within 3 months of admission, in-hospital megacolon, bowel perforation, hemodynamic shock, or respiratory failure.


RESULTS
The primary outcome occurred in 12% of patients given the combination treatment vs none of the patients given antibiotics alone (P = .01). UC, abdominal tenderness, or severe bloody diarrhea was more common among patients that received the combined therapy. However, multivariate analysis revealed that only the combination therapy maintained a trend for an independent association with the primary outcome (likelihood ratio = 11.9; CI, 0.9-157; P = .06). Treatment with 2 or 3 immunomodulators was correlated with the primary outcome, independent of disease severity at presentation (odds ratio [OR] = 17; CI, 3.2-91; P < .01). Acid-suppressing medications increased the risk of C difficile relapse (OR = 3.8; CI, 1.1-12.9; P = .03), whereas recent hospitalization correlated with increased rate of C difficile persistence (OR = 8; CI, 2.1-29; P = .002).


CONCLUSIONS
Patients with IBD that also have C difficile infection are frequently treated with a combination of antibiotics and immunomodulators. However, this combination tends to associate with a worse outcome than antibiotic therapy alone. Prospective controlled trials are urgently needed to optimize the management of these challenging patients.
Ben-Horin
Shomron
S
Sheba Medical Center, Tel-Aviv University, Israel. sben-horin@013.net.il
Margalit
Maya
M
Bossuyt
Peter
P
Maul
Jochen
J
Shapira
Yami
Y
Bojic
Daniela
D
Chermesh
Irit
I
Al-Rifai
Ahmad
A
Schoepfer
Alain
A
Bosani
Matteo
M
Allez
Matthieu
M
Lakatos
Peter Laszlo
PL
Bossa
Fabrizio
F
Eser
Alexander
A
Stefanelli
Tommaso
T
Carbonnel
Franck
F
Katsanos
Konstantinos
K
Checchin
Davide
D
Miera
Inés Sáenz de
IS
Chowers
Yehuda
Y
Moran
Gordon William
GW
D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D016360:Clostridioides difficile; D003082:Colectomy; D003093:Colitis, Ulcerative / Q000150:complications / Q000188:drug therapy* / Q000473:pathology / Q000601:surgery; D003424:Crohn Disease / Q000150:complications / Q000188:drug therapy* / Q000473:pathology / Q000601:surgery; D004359:Drug Therapy, Combination; D004761:Enterocolitis, Pseudomembranous / Q000150:complications / Q000188:drug therapy* / Q000473:pathology / Q000601:surgery; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007155:Immunologic Factors / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents; D007155:Immunologic Factors