Combination Immunomodulator and Antibiotic Treatment in Patients With Inflammatory Bowel Disease and Clostridium difficile Infection

Shomron Ben-Horin, Maya Margalit, Peter Bossuyt, Jochen Maul, Yami Shapira, Daniela Bojic, Irit Chermesh, Ahmad Al-Rifai, Alain Schoepfer, Matteo Bosani, Matthieu Allez, P. Lakatos, Fabrizio Bossa, Alexander Eser, Tommaso Stefanelli, Franck Carbonnel, Konstantinos Katsanos, Davide Checchin, Inés Sáenz de Miera, Yehuda ChowersGordon William Moran

Research output: Article

96 Citations (Scopus)

Abstract

Background & Aims: 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.

Original languageEnglish
Pages (from-to)981-987
Number of pages7
JournalClinical Gastroenterology and Hepatology
Volume7
Issue number9
DOIs
Publication statusPublished - szept. 2009

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Clostridium Infections
Clostridium difficile
Immunologic Factors
Inflammatory Bowel Diseases
Anti-Bacterial Agents
Therapeutics
Odds Ratio
Ulcerative Colitis
Infection
Megacolon
Colectomy
Colitis
Respiratory Insufficiency
Diarrhea
Shock
Hospitalization
Multivariate Analysis
Hemodynamics
Outcome Assessment (Health Care)
Recurrence

ASJC Scopus subject areas

  • Gastroenterology
  • Hepatology

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Combination Immunomodulator and Antibiotic Treatment in Patients With Inflammatory Bowel Disease and Clostridium difficile Infection. / Ben-Horin, Shomron; Margalit, Maya; Bossuyt, Peter; Maul, Jochen; Shapira, Yami; Bojic, Daniela; Chermesh, Irit; Al-Rifai, Ahmad; Schoepfer, Alain; Bosani, Matteo; Allez, Matthieu; Lakatos, P.; Bossa, Fabrizio; Eser, Alexander; Stefanelli, Tommaso; Carbonnel, Franck; Katsanos, Konstantinos; Checchin, Davide; Miera, Inés Sáenz de; Chowers, Yehuda; Moran, Gordon William.

In: Clinical Gastroenterology and Hepatology, Vol. 7, No. 9, 09.2009, p. 981-987.

Research output: Article

Ben-Horin, S, Margalit, M, Bossuyt, P, Maul, J, Shapira, Y, Bojic, D, Chermesh, I, Al-Rifai, A, Schoepfer, A, Bosani, M, Allez, M, Lakatos, P, Bossa, F, Eser, A, Stefanelli, T, Carbonnel, F, Katsanos, K, Checchin, D, Miera, ISD, Chowers, Y & Moran, GW 2009, 'Combination Immunomodulator and Antibiotic Treatment in Patients With Inflammatory Bowel Disease and Clostridium difficile Infection', Clinical Gastroenterology and Hepatology, vol. 7, no. 9, pp. 981-987. https://doi.org/10.1016/j.cgh.2009.05.031
Ben-Horin, Shomron ; Margalit, Maya ; Bossuyt, Peter ; Maul, Jochen ; Shapira, Yami ; Bojic, Daniela ; Chermesh, Irit ; Al-Rifai, Ahmad ; Schoepfer, Alain ; Bosani, Matteo ; Allez, Matthieu ; Lakatos, P. ; Bossa, Fabrizio ; Eser, Alexander ; Stefanelli, Tommaso ; Carbonnel, Franck ; Katsanos, Konstantinos ; Checchin, Davide ; Miera, Inés Sáenz de ; Chowers, Yehuda ; Moran, Gordon William. / Combination Immunomodulator and Antibiotic Treatment in Patients With Inflammatory Bowel Disease and Clostridium difficile Infection. In: Clinical Gastroenterology and Hepatology. 2009 ; Vol. 7, No. 9. pp. 981-987.
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abstract = "Background & Aims: 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.",
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AU - Ben-Horin, Shomron

AU - Margalit, Maya

AU - Bossuyt, Peter

AU - Maul, Jochen

AU - Shapira, Yami

AU - Bojic, Daniela

AU - Chermesh, Irit

AU - Al-Rifai, Ahmad

AU - Schoepfer, Alain

AU - Bosani, Matteo

AU - Allez, Matthieu

AU - Lakatos, P.

AU - Bossa, Fabrizio

AU - Eser, Alexander

AU - Stefanelli, Tommaso

AU - Carbonnel, Franck

AU - Katsanos, Konstantinos

AU - Checchin, Davide

AU - Miera, Inés Sáenz de

AU - Chowers, Yehuda

AU - Moran, Gordon William

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N2 - Background & Aims: 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.

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