Management of Recurrent Clostridioides Infection: A Difficile Problem in Inflammatory Bowel Disease Patients
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MULTICENTER SEMINARS: IBD (MUSE: IBD)
Management of Recurrent Clostridioides Infection: A Difficile Problem in Inflammatory Bowel Disease Patients Angela Y. Lam1 · Liat S. Gutin1 · Yume Nguyen2 · Fernando S. Velayos1
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Case Presentation Background A 24-year-old woman with pancolonic ulcerative colitis (UC), complicated by primary sclerosing cholangitis (PSC) requiring orthotopic liver transplant (OLT), history of rotavirus infection, and Clostridioides difficile infection (CDI), was evaluated for ongoing care. Her past therapies for UC included 6-mercaptopruine, infliximab, and adalimumab. Her current therapy includes vedolizumab and tacrolimus monotherapy as an antirejection therapy. She reports 8 bowel movements per day which are soft and liquid, including 1–2 bowel movements at night. She reports trace blood in the stool, mild right-sided abdominal cramping, and occasional urgency. Prior colonoscopies revealed moderate–severe pancolitis. Multiple prior stool tests in the prior 1–2 years have been negative for CDI. Her calculated simple clinical colitis activity index (SCCAI) was 6 (≤ 2 signifies remission). Using shared decision making, potential changes in therapy were discussed. A C. difficile stool test ordered prior to initiating any changes in therapy was positive.
Clinical Course After a 2-week course of oral vancomycin, bowel movements improved to 2–3/day. Her symptoms recurred after a month, and she received an extended 6-week vancomycin Angela Y. Lam and Liat S. Gutin have contributed equally to this work. * Fernando S. Velayos [email protected] 1
Department of Gastroenterology and Hepatology, Kaiser Permanente, 2350 Geary Boulevard, 2nd Floor, San Francisco, CA 94010, USA
Department of Gastroenterology and Hepatology, Kaiser Permanente, South San Francisco, CA, USA
2
taper which again reduced her bowel movements to 2–3 per day. Three months after completing the prolonged taper of oral vancomycin, she became symptomatic from a colitis standpoint; repeat testing for C. difficile was negative. Vedolizumab drug concentration was adequate at 15.4 with no antibodies present. Colonoscopy demonstrated a Mayo 3 subscore pancolitis with pathology showing chronic and focally active colitis throughout the colon. Clostridioides difficile checked after this colonoscopy was now positive. The patient received an additional course of oral vancomycin with a reduction in bowel movements to 3/day and is currently on a prolonged taper as the next steps are determined.
Case Discussion Clostridioides difficile is a Gram-positive, spore-forming anaerobic bacillus that causes colitis and approximately 25% of all antibiotic-associated diarrhea, with symptoms ranging from mild diarrhea to severe disease (high fever, ileus, colonic dilation, or megacolon possibly complicated by perforation). Frequently implicated antibiotics include clindamycin, ampicillin, amoxicillin, and cephalosporins, though all antibiotics have been associated with C.
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