Gastrointestinal Disorders

Christina Ha, MD, on Diagnosing and Treating C difficile in Patients With IBD

Christina Y. Ha, MD, provides a review of her presentation on the management of Clostridioides difficile infection among patients with inflammatory bowel disease, which she gave at the virtual Advances in Inflammatory Bowel Diseases Regional Meeting. 

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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. 


Christina Ha:  Hi. My name is Christina Ha. I'm an associate professor at Cedars‑Sinai and part of their Inflammatory Bowel Disease Center. I hope you enjoyed the presentation about the role of C. difficile infection for our IBD patients. I just wanted to give you some take‑home points.

First and foremost, don't forget to make the diagnosis and to rule it out. C. difficile infection can present just like an inflammatory colitis flare, with symptoms of fever, abdominal cramping, and diarrhea that can be bloody.

It is important to recognize C. difficile infection early because it is associated with increased morbidity, in‑hospital mortality, hospitalizations, and surgery, particularly for patients who are older, with more comorbidities and on steroids particularly higher doses. What's tricky is, for IBD patients, sometimes there can be colonization with C. difficile versus the true infection.

If you have a clinical suspicion that C. difficile infection may be playing a role in the symptoms due to an acute presentation of a flare, it is important to check with a two‑step process. The first test is either with the GDH assay or the PCR testing. If that's positive, that should be followed by the enzyme immunosorbent assay testing (the EIA).

If both are positive, that's a true infection. If the PCR or GDH is positive, but the EIA is negative, that's likely colonization. The focus should be on optimizing the underlying IBD treatment. Now if there is C. difficile infection, you should treat the underlying infection first with the best strategies. Those are vancomycin or fidaxomicin.

There is no role for oral metronidazole for C. difficile infection, particularly with the IBD patients. If there's no response after 72 to 96 hours, then the focus should be on adding treatments to optimize the underlying inflammatory bowel disease.

There is potentially a role for fecal microbial transplant for the treatment of C. difficile for IBD patients as demonstrated by the preliminary results from the ICON Study by my colleague at Brigham and Women's, Jessica Allegretti.

However, in the setting of COVID‑19, fecal microbial transplants are temporarily on hold until we get a better handle of what fecal transplant roles are in the setting of a pandemic. There is the potential to use some of the newer agents like bezlotoxumab. However, they should be reserved for truly refractory cases. That's when you'd want to bring your infectious disease colleagues on board.

In summary, C. difficile infection is very important to recognize. It's very important to treat early on. We have to remember that we still need to optimize the underlying IBD treatment even though there is an infection because the outcomes are worse, particularly for older patients with comorbidities.

Thank you so much for your attention. I hope this presentation was helpful.