title: Combination immunomodulator and antibiotic treatment in patients with inflammatory bowel disease and clostridium difficile infection.
abstract: 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.
authors.affiliation: Sheba Medical Center, Tel-Aviv University, Israel. sben-horin@013.net.il
authors.forename: Shomron
authors.initials: S
authors.lastname: Ben-Horin
authors.forename: Maya
authors.initials: M
authors.lastname: Margalit
authors.forename: Peter
authors.initials: P
authors.lastname: Bossuyt
authors.forename: Jochen
authors.initials: J
authors.lastname: Maul
authors.forename: Yami
authors.initials: Y
authors.lastname: Shapira
authors.forename: Daniela
authors.initials: D
authors.lastname: Bojic
authors.forename: Irit
authors.initials: I
authors.lastname: Chermesh
authors.forename: Ahmad
authors.initials: A
authors.lastname: Al-Rifai
authors.forename: Alain
authors.initials: A
authors.lastname: Schoepfer
authors.forename: Matteo
authors.initials: M
authors.lastname: Bosani
authors.forename: Matthieu
authors.initials: M
authors.lastname: Allez
authors.forename: Peter Laszlo
authors.initials: PL
authors.lastname: Lakatos
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Bossa
authors.forename: Alexander
authors.initials: A
authors.lastname: Eser
authors.forename: Tommaso
authors.initials: T
authors.lastname: Stefanelli
authors.forename: Franck
authors.initials: F
authors.lastname: Carbonnel
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Katsanos
authors.forename: Davide
authors.initials: D
authors.lastname: Checchin
authors.forename: Inés Sáenz de
authors.initials: IS
authors.lastname: Miera
authors.forename: Yehuda
authors.initials: Y
authors.lastname: Chowers
authors.forename: Gordon William
authors.initials: GW
authors.lastname: Moran
mesh_terms: 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
chemical_list: D000900:Anti-Bacterial Agents; D007155:Immunologic Factors