From the Guidelines
In a patient with fulminant C. difficile sepsis and suspected Crohn's disease, steroids should generally be held until the C. difficile infection is controlled. The priority should be treating the acute C. difficile infection with appropriate antibiotics such as oral vancomycin (125 mg four times daily) or fidaxomicin (200 mg twice daily) for 10-14 days, as suggested by recent guidelines 1. Adding intravenous metronidazole (500 mg every 8 hours) may be beneficial in severe cases. Steroids, while beneficial for Crohn's disease flares, can worsen infectious processes by suppressing the immune response and potentially allowing the C. difficile infection to progress, as noted in studies on the management of inflammatory bowel disease 1.
Once the C. difficile infection shows clear signs of improvement (decreased fever, improved white blood cell count, reduced diarrhea), steroids could be cautiously introduced to manage the suspected Crohn's disease, following recommendations for the use of corticosteroids in Crohn’s disease 1. This approach balances the competing needs of treating the immediate life-threatening infection while not neglecting the underlying inflammatory bowel disease. Close monitoring for clinical response and complications is essential throughout this process, considering the potential risks and benefits of steroid use in patients with Crohn's disease, as outlined in guidelines for the management of luminal Crohn's disease 1.
Key considerations include:
- The use of systemic corticosteroids for moderate to severely active Crohn’s disease, as recommended by the British Society of Gastroenterology 1.
- The suggestion against the use of oral corticosteroids to maintain complete remission in patients with Crohn’s disease, as per the Canadian Association of Gastroenterology 1.
- The importance of antimicrobial stewardship and prevention of healthcare-associated C. difficile infection, as emphasized in the second European evidence-based consensus on the prevention, diagnosis, and management of opportunistic infections in inflammatory bowel disease 1.
From the Research
Management of Fulminant C. diff Sepsis in Patients with Suspected Crohn's Disease
- The use of steroids in patients with fulminant C. diff sepsis who are suspected of having Crohn's Disease is a complex issue, and the decision to use or hold steroids should be individualized 2.
- According to the expert review by the Clinical Practice Updates Committee of the AGA Institute, clinicians may postpone escalation of steroids and other immunosuppression agents during acute C. difficile infection until therapy for C. difficile infection has been initiated 2.
- However, there is insufficient existing robust literature on which to develop firm recommendations, and the decision to withhold or continue immunosuppression in inflammatory bowel disease patients with C. difficile infection should be made on a case-by-case basis 2.
- The primary focus should be on treating the C. difficile infection, and vancomycin is recommended as the first-line therapy for patients with fulminant disease 3, 4.
- In patients with fulminant C. difficile infection, oral vancomycin reduces mortality, and adjunctive therapies (including IV metronidazole) and interventions (including fecal microbiota transplant) may benefit select patients 3.
- The use of fidaxomicin has also been shown to be effective in treating C. difficile infection, with a lower rate of recurrence compared to vancomycin 4, 5.
Key Considerations
- The decision to use or hold steroids should be individualized and based on the patient's specific clinical situation 2.
- The primary focus should be on treating the C. difficile infection, and vancomycin is recommended as the first-line therapy for patients with fulminant disease 3, 4.
- Clinicians should be aware of the potential risks and benefits of using steroids in patients with fulminant C. diff sepsis and suspected Crohn's Disease, and should carefully monitor the patient's response to treatment 2, 3.