What is the best initial management for a patient with Crohn's disease on Infliximab (infliximab) who presents with a perianal discharging fistula, induration, and low-grade fever?

From the Guidelines

The best initial management for a patient with Crohn's disease on infliximab who presents with a perianal discharging fistula, induration, and low-grade fever is prompt surgical drainage of the perianal abscess combined with broad-spectrum antibiotics.

Key Considerations

• Ciprofloxacin 500 mg twice daily and metronidazole 500 mg three times daily should be started immediately and continued for 1-2 weeks.
• The patient should continue their infliximab therapy as scheduled, as discontinuation could worsen the underlying Crohn's disease.
• After drainage, MRI of the pelvis should be obtained to evaluate the fistula tract anatomy and exclude deeper abscesses.
• Seton placement may be necessary during surgical drainage to maintain patency of the fistula tract and prevent recurrent abscess formation.
• Pain management with acetaminophen or, if necessary, low-dose opioids should be provided.

Rationale

This approach addresses both the infectious complication (abscess) and the underlying inflammatory disease. The antibiotics target the polymicrobial infection typically involving enteric gram-negative bacteria and anaerobes, while continuing infliximab helps control the inflammatory component of Crohn's disease that contributes to fistula formation and persistence.

Evidence Support

The ECCO guidelines on therapeutics in Crohn's disease support the use of infliximab for the induction and maintenance of remission in complex perianal fistulae in Crohn’s disease 1. Additionally, the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults recommend the use of infliximab for perianal fistulising disease 1.

Follow-Up

Close follow-up within 1-2 weeks is essential to monitor response to treatment and adjust the management plan accordingly.

Additional Considerations

Measurement of drug and antibody levels can be helpful in guiding next steps in patients who experience secondary loss of response to infliximab 1. The AGA clinical practice guidelines on the medical management of moderate to severe luminal and perianal fistulizing Crohn's disease recommend the use of infliximab for the induction and maintenance of remission in patients with fistulizing disease 1.

From the FDA Drug Label

Fistulizing Crohn's Disease in Adults The safety and efficacy of REMICADE were assessed in 2 randomized, double-blind, placebo-controlled studies in adult patients with fistulizing CD with fistula(s) that were of at least 3 months duration. Patients who achieved a fistula response and subsequently lost response were eligible to receive REMICADE maintenance therapy at a dose that was 5 mg/kg higher than the dose to which they were randomized Of the placebo maintenance patients, 66% (25/38) responded to 5 mg/kg REMICADE, and 57% (12/21) of REMICADE maintenance patients responded to 10 mg/kg.

The best initial management for a patient with Crohn's disease on Infliximab who presents with a perianal discharging fistula, induration, and low-grade fever is not explicitly stated in the provided drug label. However, based on the information provided, the management of fistulizing Crohn's disease with Infliximab is described, but the specific scenario of a patient presenting with a perianal discharging fistula, induration, and low-grade fever while already on Infliximab is not directly addressed.

• The drug label discusses the use of Infliximab in patients with fistulizing Crohn's disease, but it does not provide guidance on how to manage a patient who is already on Infliximab and presents with these specific symptoms.
• It is important to note that the management of such a patient would likely involve a multidisciplinary approach, including assessment of the patient's current Infliximab dose and potential adjustment, as well as consideration of other treatments such as antibiotics.
• Given the lack of direct guidance in the drug label, the best course of action would be to consult with a specialist and consider the individual patient's circumstances and medical history when determining the best management approach 2.

From the Research

Management of Airway in RTA Patient with Multiple Mandibular Fractures

• In a patient with multiple mandibular fractures and severe bleeding, unconscious, and no vitals mentioned, the management of the airway is crucial 3.
• The best option for managing the airway in this patient would be Cricothyrotomy (D), as it is a rapid and effective way to establish an airway in a patient with severe facial trauma and potential cervical spine injury.
• Other options such as Laryngeal mask (A), Orotracheal (B), and Nasotracheal (C) may not be feasible due to the severity of the facial trauma and potential bleeding.

Vessels Affected in Rectus Muscle Reconstruction

• In a patient undergoing reconstruction from rectus muscle, the vessels that may be injured or affected are:

• Inferior Epigastric Artery (A)

• The Superior Epigastric artery (B) may also be affected, but it is not the primary vessel of concern in rectus muscle reconstruction.

Management of Perianal Discharging Fistula in Crohn's Disease Patient

• In a patient with Crohn's disease on infliximab who presents with a perianal discharging fistula, induration, and low-grade fever, the best initial management would be:

• Antibiotics then assess infliximab level (B) 4, 5, 6, 7

• This approach allows for the treatment of any underlying infection and assessment of the patient's response to infliximab, which may guide further management decisions.
• Other options such as Increase dose of infliximab (A), Swab from discharge (C), and MRI (D) may be considered as part of the overall management plan, but are not the best initial step.