Inflammatory bowel disease and Clostridium difficile infection: contrasting views of international clinical professionals

Abstract

Introduction In patients with inflammatory bowel disease (IBD), Clostridium difficile infection (CDI) is a risk factor for both morbidity and mortality. Currently, appropriate management is unclear. Guidance on best practice in the diagnosis and treatment of CDI in IBD patients is therefore needed.

Methods A multidisciplinary group of clinicians involved in the treatment of patients with IBD and CDI developed 27 consensus statements. Respondents were asked to rate their agreement with each statement using a 4-point Likert scale. A modified Delphi methodology was used to review responses of 442 physicians from different specialties (including infectious disease specialists [n = 104], microbiologists [n = 95], and gastroenterologists [n = 73]). A threshold of 75 % agreement was predefined as consensus.

Results Consensus was achieved for 17 of the 27 statements. Unprompted recognition of risk factors for CDI was low. Intensification of immunosuppressive therapy in the absence of clinical improvement was controversial. Clear definitions of treatment failure of antibiotic therapy in CDI and recurrence of CDI in IBD are needed. Respondents require further clarity regarding the place of fecal microbiota transplantation in CDI patients with IBD. Differences were observed between the perceptions of microbiologists and gastroenterologists, as well as between countries.

Conclusions Different perceptions both between specialties and geographical locations complicate the development of an internationally accepted algorithm for the diagnosis and treatment of CDI in patients with IBD. This study highlights the need for future studies in this area.

Zusammenfassung

Einleitung Bei Patienten mit chronisch-entzündlichen Darmerkrankungen (CED) stellt die Clostridium difficile Infektion (CDI) ein Risikofaktor für eine erhöhte Morbidität und Mortalität da. Ein international akzeptierter Konsensus zur Diagnostik und Therapie dieser Komplikation ist nicht etabliert.

Methoden Eine interdisziplinäre Gruppe von Experten, entwickelten in zwei Konsensuskonferenzen 27 Aussagen zur Diagnostik und Therapie der CDI bei Patienten mit CED. In einem modifizierten Delphi-Prozess wurden 442 Ärzte aus unterschiedlichen Schwerpunkten (u. a. Infektiologen [n = 104], Mikrobiologen [n = 95], Gastroenterologen [n = 73]) befragt, um ihre Zustimmung oder Ablehnung zu jeder Aussage in einer 4-Punkt-Likert-Skala auszudrücken. Ein Schwellenwert von 75 % wurde als Konsens vordefiniert.

Ergebnisse Für 17 der 27 Aussagen konnte ein Konsens erreicht werden. Unklar bleibt, welche Risikofaktoren eine CDI bedingen. Kontrovers wird die Frage der Intensivierung einer immunsuppressiven Therapie bei fehlender klinischer Besserung gesehen. Auch besteht ein großer Bedarf, wie das Therapieversagen einer antibiotischen Therapie bei CDI bzw. ein Rezidiv der CDI bei CED definiert werden kann. Zur Bedeutung des fäkalen Mikrobiomtransfers bei CDI und CED gab es keinen allgemeinen Konsens. Es zeigten sich zu einigen Aussagen auch deutliche Unterschiede zwischen Mikrobiologen und Gastroenterologen sowie zwischen den Ländern.

Schlussfolgerung Unterschiede in der Bewertung erschweren die Entwicklung eines international akzeptierten Algorithmus zur Diagnostik und Therapie der CDI bei Patienten mit CED. Diese Studie zeigt die Defizite und Schwierigkeiten in der Diagnostik und Therapie der CDI bei CED auf und formuliert den Bedarf für zukünftige Studien.

Schlüsselwörter

Chronisch-entzündliche Darmerkrankung - Clostridium difficile Infektionen - Konsensbericht

Key words

inflammatory bowel disease - clostridium difficile infection - consensus report

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