In this podcast, Christina Y. Ha, MD, provides insight into the prevention and management of Clostridioides difficile infection among patients with inflammatory bowel disease. It is a topic she will be discussing at the upcoming virtual Advances in Inflammatory Bowel Diseases Regional Meeting.
Christina Y. Ha, MD, is an associate professor of medicine and director of the Inflammatory Bowel Disease fellowship at Cedars-Sinai Medical Center in Los Angeles, California.
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TRANSCRIPT:
Colleen Murphy: Hello, everyone, and welcome to another installment of “Podcast 360,” your go‑to resource for medical news and clinical updates. I’m your moderator, Colleen Murphy, with Consultant360 Specialty Network.
This month is the Advances in Inflammatory Bowel Diseases Regional meeting. It will be a day filled with expert insight into the optimal management of IBD, with a focus on how to overcome the disease’s clinical challenges. One such unique consideration clinicians may face among patients with IBD is the prevention and management of C difficile infection.
Dr Christina Ha, an associate professor of medicine at Cedars‑Sinai Medical Center, will be presenting about the topic at the meeting. She joins me today to give insight into how to prevent C difficile, as well as how to achieve better patient outcomes for those with IBD who do develop the infection. Thank you for talking with me today, Dr Ha.
Christina Ha: Thank you for having me.
CM: So are you all geared up for the AIBD Regional meeting?
CH: Yes, looking forward to it. We have great speakers, and it’s always a very educational conference with a lot of very clinically practical topics.
CM: Like I mentioned, you’ll be covering not only C diff prevention, but also management. But let’s start with prevention first. Preventing C diff in any patient is key, but why is it especially vital for a patient with IBD?
CH: That’s a great question, and it’s really important for inflammatory bowel disease patients because C difficile has a greater prevalence in the IBD patients than the non‑IBD patients. When an IBD patient—particularly those with inflammatory colitis, whether it be Crohn colitis or ulcerative colitis—get the C difficile infection, it’s associated with greater likelihoods of hospitalizations, disease flares, colectomies, failures of not only C difficile infection‑related therapy, but also failures of inflammatory bowel disease‑related therapy. So there’s a lot of downstream effects for having a C difficile infection, so the idea is the earlier we can identify it, hopefully, the earlier we can intervene in a successful manner.
CM: Absolutely. What are some of the best practices for prevention of C difficile among patients with IBD and the challenges to achieving them?
CH: The main principles are still the same principles as for the general population. We want to avoid excessive use or unnecessary use of antibiotics. Oftentimes across the board, regardless of whether you have IBD or not, we prescribe or recommend antibiotics for many conditions where they’re not necessary.
We oftentimes recommend if you have a cold‑like symptom, don’t automatically jump to the antibiotics because, by far, most of those are viral-related etiologies. But if you do need antibiotics, try to stick to the shortest course possible, and always just monitor your symptoms carefully.
We do know of the IBD-related medications, one that’s probably the most associated with C difficile infection risk is steroids. Across the board, we don’t like to keep anybody with Crohn disease or ulcerative colitis on steroids for too long, not only because of the downstream effects of chronic steroid exposure, but because it does increase the risk for C difficile.
And not just for C difficile, but overall, it’s very important to utilize appropriate sanitation practices. And that certainly includes washing your hands. The difference with C difficile compared to some of the other bacterial viruses and fungi that are out there is that alcohol foams or the hand sanitizers are really ineffective at killing the spores. So the best practices are to wash your hands carefully, at least 20 seconds in warm water with soap, and to dry them carefully. Those are the same recommendations that we would make for our IBD patients.
However, if they notice symptoms of increased cramping, diarrhea, bleeding—which could mimic a Crohn disease or ulcerative colitis flare—[I] also remind all my colleagues to check for C difficile. Even if they’ve had a negative C difficile in the past, it can crop up at any time, even without exposure to steroids or antibiotics.
CM: That’s great. You just mentioned some of the ways to prevent C difficile. However, let’s say a patient with IBD does have C difficile. Your focus at this point is obviously not on prevention, but on achieving the best outcome. What are some of the best practices and, again, their challenges to achieving good outcome?
CH: Well the first is to make sure that it’s truly a C difficile infection and not just colonization, because a lot of our patients may be colonized with C difficile. And what I mean by that is that most common commercial testing that’s done to check for the presence of C difficile is the C difficile qualitative PCR test. And that’s oftentimes positive, even if you may not truly have the infection, so you do need a second confirmatory test. That’s usually the enzyme immunosorbent assay, or the EIA, for toxin A and B. If you have both of those, the PCR and the EIA for toxin positive, then it’s truly an infection. If the PCR is positive and the EIA is negative and the patient’s having symptoms, it’s more likely due to their underlying inflammatory bowel disease.
That’s the first step is to make sure we’re treating the right thing. If they do have C difficile infection, automatically, by simply just having a diagnosis of inflammatory colitis, we should be treating them as though they have severe disease. According to the Infectious Diseases Society of America and our recent ACG guidelines, the first‑line treatment is vancomycin.
There’s no role for doses higher than 125 milligrams, 4 times daily, so vancomycin tends to be the first‑line treatment. If somebody cannot tolerate vancomycin, another option is fidaxomicin at 200 milligrams, twice daily, for 10 days. But our first‑line treatment for C difficile is first to confirm that it truly is the infection. The second is to use vancomycin as first‑line, or potentially fidaxomicin if there’s a contraindication. The third is to also make sure that you don’t forget to treat the underlying inflammatory bowel disease, as C difficile infection can make the underlying inflammatory colitis worse.
CM: You just mentioned a couple of guideline recommendations about the treatment of C difficile. Do you think there are any overarching widespread improvements that are needed, whether it be a particular guideline update, best practice recommendations, or further research to improve prevention and management of C difficile?
CH: We do know that, unfortunately, C difficile can recur, and really differentiating recurrent C difficile infection amongst our IBD patients vs failure of medical therapy is something that can be a little bit challenging. We don’t recommend retesting after treatment to confirm eradication because the toxin can be present for weeks after the initial infection.
But other areas that are in need of further study—and I have great colleagues such as Jessica Allegretti at Brigham and Women, Colleen Kelly at Brown, as well as Monika Fisher at Indiana University, who are investigating this—is to look at what are some of the outcomes of some of our other therapies for recurrent or refractory C difficile on our IBD patients, particularly if they’re on immunosuppression, and those are therapies such as fecal microbial transplantation, or some of the other monoclonal antibodies that are now FDA approved to treat recurrent C difficile such as bezlotoxumab. That’s an area where we don’t know enough, and I think that over the next few years, as more of these studies become published, we’ll have more information on how to manage it.
CM: Well it certainly sounds like there is exciting research in the pipeline. Considering the current management techniques out there, and based on what you will be discussing in your presentation, what would you like attendees to take away from your presentation and implement into their everyday practice?
CH: The first thing is, if a patient’s presenting with an inflammatory colitis flare, it’s important to rule out C difficile infection, and don’t rely on past negative results. It’s important to rule that out at the same time as you’re doing your other investigations as to the cause of the flare, or you’re working out your next step of treatment. If a patient does have C difficile infection, it’s important to treat them appropriately. Even before the testing comes back, if you have a high clinical suspicion that C difficile infection may be there, oftentimes, I’ll even empirically treat with vancomycin until I have the test results back. Certainly, if the test result is positive, make sure you’re using vancomycin, 125 milligrams, 4 times daily as your first‑line treatment for 14 days. Then assess for response. The alternative is fidaxomicin, and again, that can be 20 milligrams, twice daily, for 10 days, and assess response.
At the same time, however, because of the C difficile impact on the inflammatory colitis, do not withhold their immunosuppression. Oftentimes, their immunosuppression regimens need to be optimized.
If you’re thinking when you do the sigmoidoscopy to assess for disease activity, that there’s moderate to severe disease, and you need to move on to a biologic or small molecule, do so because underlying C difficile will increase their risk for hospitalizations, longer length of stay, and colectomy.
Delaying the appropriate immunosuppressive regimen for the inflammatory colitis while you’re treating the C difficile will result in bad outcome. Also, along the way, you have to counsel your patients as well as their caregivers about appropriate hand hygiene to prevent recurrences and spread. That’s good practice overall.
CM: Interesting that you also included, not just the patients themselves, but their caregivers as well. Well, Dr Ha, that’s actually all I have for you. Is there anything else you’d like to add that we haven’t talked about?
CH: The last thing I’d say is, we get a lot of questions about the role of fecal transplant as an initial therapy for our patients with C difficile infection. It is not approved as an initial therapy for our inflammatory bowel disease patients. But certainly, if you have a patient who’s had recurrent C difficile infection—not their first recurrence, but with their second recurrence—it is appropriate, and you should consider referring them to a center that does fecal microbial transplants. Because even though the data is limited thus far, there’s still good data that suggest similar or maybe slightly lower rates of efficacy compared to people who don’t have inflammatory colitis. But it’s certainly a very good treatment option for some patients, so with their second recurrence, I would also recommend consideration for referral for fecal transplant.
CM: Dr Ha, thank you again for speaking with me. I hope your time at the AIBD Regional meeting is a success. It seems like your peers in attendance have an interesting presentation to look forward to. I’m glad those not in attendance can get a glimpse into your insight as well.
CH: Thank you so much for having me. It was great talking with you.