Infections in Inflammatory Bowel Disease Clinical Practice Guidelines (ECCO, 2021)

European Crohn’s and Colitis Organisation

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

August 10, 2021

Clinical guidelines regarding infections in patients with inflammatory bowel disease (IBD), including their prevention, diagnosis, and management, were published in March 2021 by the European Crohn's and Colitis Organisation (ECCO) in the Journal of Crohn's and Colitis.[1]

IBD patients treated with immunosuppressive agents (particularly in combination) are at risk for opportunistic infections. Malnutrition, obese body mass index (BMI), comorbidities, active disease, and older age are also predictors for such infections.

It is recommended that all IBD patients undergo serologic screening for hepatitis A, B, and C; human immunodeficiency virus (HIV); Epstein-Barr virus; cytomegalovirus (CMV); varicella-zoster virus (VZV); and measles virus (with such screening taking place for the last two if the patient does not have documented evidence of past infection or has not been vaccinated). Screening should be carried out at baseline and especially before or during immunosuppressive therapy. In addition, a Pap smear should be performed to screen for human papillomavirus.

There is a significant chance that symptomatic varicella-zoster virus reactivation will occur in patients with IBD. Owing to its efficacy and safety, the preferred vaccine for patients with IBD is recombinant herpes zoster vaccine (RZV). If RZV is unavailable, it is recommended that a live zoster vaccine be administered to immunocompetent patients with IBD aged 50 years or older. Also, in patients on low-dose immunosuppression, a live zoster vaccine can be considered if RZV is not available.

The prognosis for active IBD is worsened by concurrent CMV colitis. If the IBD is refractory, the patient should be tested for CMV colitis, especially if the individual fails to respond to immunosuppressive therapy.

Do not discontinue immunosuppressive therapy in IBD patients with intestinal CMV reactivation in general. Steroid tapering should be performed, and consideration should be given to antiviral therapy in steroid-refractory IBD patients with CMV colitis. It is recommended that immunosuppressive therapy be discontinued in symptomatic disseminated CMV infection.

Appropriate antiviral treatment should be provided to immunosuppressed IBD patients with an ongoing herpes simplex virus (HSV), VZV, or influenza infection.

If, prior to biologic or small-molecule therapy or prolonged treatment with high-dose systemic steroids, a patient has been diagnosed with latent tuberculosis infection (LTBI), the individual should undergo treatment with a complete therapeutic regimen for LTBI. In other situations, seek out specialist advice. Biologic or small-molecule therapy should be delayed for at least 4 weeks post chemotherapy in a patient with active IBD who also has LTBI, except when there is greater clinical urgency (and in correlation with specialist advice).

Non-severe Clostridioides difficile infection (CDI) can be treated to equal effect with 10 days of oral vancomycin or fidaxomicin. For severe CDI, add intravenous metronidazole to oral vancomycin for 10 days. If CDI recurs, treatment includes oral vancomycin, fidaxomicin, fecal microbiota transplantation, and bezlotoxumab. Following careful risk-benefit evaluation and clinical judgement, immunosuppressant use can be maintained in patients with CDI.

The fungal infection risk in IBD is low. Though exceptional, systemic infections are associated with high mortality. Chemoprophylaxis is not indicated, except with Pneumocystis jirovecii. After a systemic fungal infection, discuss chemoprophylaxis with an infectious disease specialist.

Live vaccines are generally considered to be unsafe in patients with IBD who are undergoing immunosuppressive therapy. After immunosuppressive therapy has been terminated, a wait of at least 1-6 months is recommended before a live vaccine is administered. Case-by-case consideration should be given regarding the administration of any live vaccine.

For more information, please go to Inflammatory Bowel Disease.

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