What is the recommended management for a patient with a history of Crohn's (Crohn's disease) and a positive Clostridioides difficile (C. difficile) test?

Management of C. difficile Infection in Patients with Crohn's Disease

For patients with Crohn's disease and a positive C. difficile test, oral vancomycin or fidaxomicin should be used as first-line therapy, with careful monitoring for both infection resolution and underlying IBD activity. 1, 2, 3

Diagnosis Confirmation and Initial Assessment

• All patients with Crohn's disease who present with worsening gastrointestinal symptoms should be tested for C. difficile infection, as it may mimic or trigger an IBD flare 1, 4
• C. difficile testing should be performed using a two-step approach to confirm active infection rather than colonization, which is more common in IBD patients 4, 5
• Rule out other enteric pathogens that may be present, as Crohn's disease patients are more likely to have concurrent infections with norovirus and Campylobacter 1
• Assess severity of symptoms to guide treatment approach 2

Treatment Recommendations

First-line Treatment

• For non-fulminant disease: Oral vancomycin (125 mg four times daily for 10 days) or fidaxomicin (200 mg twice daily for 10 days) 3, 2, 3
• Metronidazole is no longer recommended as first-line therapy for C. difficile infection in patients with IBD 4, 5
• Fidaxomicin may be preferred due to its lower recurrence rates compared to vancomycin, particularly in high-risk patients 3, 6

Management of IBD Therapy During C. difficile Infection

• Do not escalate immunosuppressive therapy or introduce rescue therapy (infliximab or calcineurin inhibitors) in acute severe colitis associated with C. difficile infection 1
• For patients with worsening of underlying IBD symptoms who fail to improve with appropriate antimicrobial therapy alone, consider escalation of immunosuppression alongside continued antimicrobial treatment 4, 5
• Corticosteroid therapy for acute severe colitis can be continued during C. difficile treatment 1
• Decisions regarding continuation of immunomodulator therapy should be made on an individual basis, involving the surgical team in discussions 1

Monitoring and Follow-up

• Monitor renal function during and after treatment with vancomycin, especially in patients over 65 years of age 2
• Assess biomarkers of inflammation (fecal calprotectin >150 mg/g, CRP >5 mg/L) to differentiate between ongoing C. difficile infection and IBD flare 1
• After resolution of C. difficile symptoms, evaluate for endoscopic evidence of active IBD inflammation, typically 6-12 months after treatment 1

Management of Recurrent C. difficile Infection

• For recurrent C. difficile infection in IBD patients, consider fecal microbiota transplantation (FMT), which has been shown to be safe and effective in this population 4, 5
• Bezlotoxumab (monoclonal antibody) may be considered for patients at high risk for recurrence 5, 6

Special Considerations for Crohn's Disease Patients

• Patients with colonic involvement of Crohn's disease are at higher risk for C. difficile infection 4
• Patients with a history of C. difficile infection prior to surgery (such as ileal pouch-anal anastomosis) have significantly higher risk of developing post-operative C. difficile infection 7
• Newer IBD therapies including vedolizumab, ustekinumab, and tofacitinib appear less likely to cause severe C. difficile infection compared to older immunosuppressants 5

Prevention Strategies

• Implement antibiotic stewardship to reduce unnecessary antibiotic exposure 5, 6
• Minimize use of corticosteroids when possible, as they are a modifiable risk factor for C. difficile infection in IBD patients 5
• Consider infection control measures to prevent transmission, particularly in healthcare settings 5