What are the principles and considerations for managing infectious disease in patients with ulcerative colitis?

Managing Infectious Disease in Ulcerative Colitis

In patients with ulcerative colitis, prompt identification and treatment of infectious diseases is critical, with treatment of suspected infections not being delayed while awaiting stool microbiology results, as infections can trigger flares and worsen outcomes. 1

Diagnostic Approach for Infections in UC

• Stool cultures should be obtained in all patients presenting with flares of ulcerative colitis, but treatment should not be delayed pending results 1
• C. difficile screening is mandatory in all hospitalized UC patients, as UC is an independent risk factor for C. difficile infection 1
• Patients on immunomodulators require more comprehensive infectious disease screening, including tuberculosis testing (tuberculin skin test and interferon-gamma release assays) 1
• Monitoring of pulse rate, stool frequency, C-reactive protein, and plain abdominal radiography helps identify patients who may have infectious complications 1

Management of Specific Infections

C. difficile Infection

• For mild to moderate C. difficile infection, both metronidazole and oral vancomycin are effective, but vancomycin is preferred for severe disease 1
• Discontinue other antibiotics if possible to reduce risk of C. difficile recurrence 1
• Fecal microbiota transplantation is considered safe in UC patients with recurrent C. difficile 1

Tuberculosis

• Screen for latent TB before starting anti-TNF therapy using both tuberculin skin test and interferon-gamma release assays (preferred in BCG-immunized individuals) 1
• Patients with latent TB should receive anti-tuberculous therapy before starting anti-TNF therapy 1
• In patients with active UC and latent TB, anti-TNF should only be administered after at least 3 weeks of anti-TB chemotherapy 1

Bacterial Infections

• Pneumococcal vaccination should be administered 2 weeks before starting immunomodulator therapy 1
• Patients on immunomodulators who develop pneumonia should be tested for pneumococcal infections and Legionella pneumophila 1
• Immunomodulators increase the risk of severe infections with Salmonella, Listeria monocytogenes, and Nocardia species 1
• Withhold immunomodulators until active infections are resolved 1

Approach to Acute Severe UC with Suspected Infection

• Physical examination daily to evaluate abdominal tenderness and rebound tenderness 1
• Record vital signs four times daily and more frequently if deterioration is noted 1
• Maintain a stool chart to record number and character of bowel movements 1
• Measure FBC, ESR or CRP, serum electrolytes, serum albumin, and liver function tests every 24-48 hours 1
• Obtain daily abdominal radiography if colonic dilatation is detected (transverse colon diameter >5.5 cm) 1
• Administer intravenous fluid and electrolyte replacement to prevent dehydration 1
• Consider concomitant intravenous metronidazole when administering intravenous steroids for severe disease, as it may be difficult to distinguish between active disease and septic complications 1

Monitoring and Prevention Strategies

• A multimodal approach to monitoring disease activity is recommended, including clinical, biochemical, imaging, and endoscopic modalities 1
• Fecal calprotectin should be used for monitoring disease activity, but remember it can be elevated in both UC flares and intestinal infections 1
• Consider simultaneous evaluation for enteric pathogens in patients with UC who present with gastrointestinal symptoms, as approximately one-third of symptomatic UC patients have detectable gastrointestinal infections 1
• Implement appropriate vaccination strategies before initiating immunosuppressive therapy 1

Surgical Considerations

• Early surgical referral is crucial in severe or refractory UC, especially when complicated by infections 1
• Colectomy may be necessary and life-saving in patients with severe UC who develop complications such as toxic megacolon, perforation, or severe hemorrhage 1
• A laparoscopic approach is recommended in hemodynamically stable patients, while open surgery may be preferred in cases of perforation or toxic megacolon 1

Special Considerations

• Immunomodulator therapy decisions should be guided by careful risk-benefit evaluation in patients with recent C. difficile infection 1
• Anti-TNF therapy should be withdrawn during active infection and infectious disease experts should be consulted before reintroduction 1
• Joint management by gastroenterologists and colorectal surgeons is recommended for patients with severe UC, particularly when infectious complications are suspected 1