What is the relationship between Crohn's disease and sepsis?

From the Guidelines

Patients with Crohn's disease who develop sepsis require immediate, aggressive treatment to prevent rapid deterioration and potential mortality. The recommended approach is based on the most recent and highest quality study, which emphasizes the importance of prompt recognition and treatment of sepsis in Crohn's disease patients 1.

Key Components of Treatment:

• Prompt initiation of broad-spectrum intravenous antibiotics, such as:
  • Piperacillin-tazobactam 4.5g IV every 6 hours
  • Meropenem 1g IV every 8 hours
  • Add vancomycin 15-20 mg/kg IV every 8-12 hours if MRSA is suspected
• Fluid resuscitation with crystalloids, starting with a 30 mL/kg bolus and reassessing frequently
• Vasopressors (e.g., norepinephrine) if hypotension persists after fluid resuscitation
• Source control: Identify and address any abscesses or perforations, which may require surgical intervention, as recommended by the WSES-AAST guidelines 1
• Continue immunosuppressive medications for Crohn's disease, as abrupt discontinuation can worsen inflammation
• Monitor closely for complications such as toxic megacolon or intestinal perforation
• Provide nutritional support, preferably enteral if tolerated The combination of Crohn's disease and sepsis is particularly dangerous due to the compromised intestinal barrier in Crohn's patients, which can allow bacterial translocation, as noted in the ECCO guidelines on therapeutics in Crohn's disease 1.

Surgical Intervention:

Surgical intervention may be necessary in cases of bowel obstruction, perforation, or bleeding, and the approach should be tailored to the individual patient's needs, with consideration of laparoscopic or open approaches, as recommended by the WSES-AAST guidelines 1. In cases of severe sepsis or septic shock, damage control surgery may be considered, with resection, stapled off bowel ends, and temporary closure (laparostomy) with return to theatre in 24-48 hours for a second look, washout, and consideration of stoma vs anastomosis 1.

From the FDA Drug Label

The most common serious adverse reactions observed in clinical trials of infliximab were infections [see Adverse Reactions (6. 1)]. Other serious, medically relevant adverse reactions ≥ 0. Resistance Mechanism: cellulitis, sepsis, serum sickness, sarcoidosis Infections were reported in 56% of randomized pediatric patients in Study Peds Crohn's and in 50% of adult patients in Study Crohn's I In Study Peds Crohn's, infections were reported more frequently for patients who received every 8-week as opposed to every 12-week infusions (74% and 38%, respectively), while serious infections were reported for 3 patients in the every 8-week and 4 patients in the every 12-week maintenance treatment group The most commonly reported infections were upper respiratory tract infection and pharyngitis, and the most commonly reported serious infection was abscess.

Relationship between Crohn's disease and sepsis:

• Patients with Crohn's disease are at risk of developing serious infections, including sepsis, when treated with infliximab.
• The incidence of infections, including sepsis, is higher in patients with Crohn's disease compared to other conditions.
• Sepsis is listed as a serious, medically relevant adverse reaction in patients treated with infliximab, including those with Crohn's disease 2.
• The exact relationship between Crohn's disease and sepsis is not explicitly stated in the drug label, but it can be inferred that patients with Crohn's disease are at a higher risk of developing sepsis due to their increased susceptibility to infections.
• Key points to consider:
  • Infections are a common adverse reaction in patients with Crohn's disease treated with infliximab.
  • Sepsis is a serious infection that can occur in patients with Crohn's disease.
  • The risk of sepsis may be higher in patients with Crohn's disease due to their underlying condition and treatment with infliximab.

From the Research

Relationship Between Crohn's Disease and Sepsis

The relationship between Crohn's disease and sepsis is complex, with several studies highlighting the increased risk of sepsis in patients with Crohn's disease. Some key points to consider include:

• Patients with Crohn's disease are at a higher risk of developing sepsis due to complications such as intra-abdominal abscess, microperforation of the intestine, and fistula formation 3.
• The use of immunosuppressive drugs and abdominal surgery are often associated with an increased risk of sepsis in patients with Crohn's disease 3, 4.
• Sepsis can be a significant complication of Crohn's disease, and its management requires a multidisciplinary approach, including the use of nutrition therapy, such as parenteral and enteral nutrition, to stabilize the patient before initiating standard pharmacological treatment 5, 6.
• The presence of sepsis can make it challenging to manage Crohn's disease, as patients with severe infections or sepsis are often ineligible for standard treatment using biological and immunosuppressive drug regimens 5, 3.

Risk Factors for Sepsis in Crohn's Disease

Several risk factors have been identified as increasing the likelihood of sepsis in patients with Crohn's disease, including:

• Combination immunosuppression, which has been shown to increase the risk of intra-abdominal sepsis after ileocolic resection 4.
• Previous intestinal resection, which has also been associated with an increased risk of intra-abdominal sepsis 4.
• The presence of perianal disease, which can lead to recurrent perianal sepsis and impaired quality of life 7.

Management of Sepsis in Crohn's Disease

The management of sepsis in patients with Crohn's disease requires a comprehensive approach, including:

• The use of antibiotics, ventilator management, and circulatory management with massive intravenous fluids and vasoactive agents 3.
• Nutrition therapy, such as parenteral and enteral nutrition, to stabilize the patient and promote healing 5, 6.
• A multidisciplinary approach to patient care, including the use of a structured algorithm, such as the "sepsis-nutrition-anatomy-plan" algorithm, to manage patients with type 2 intestinal failure 6.