Quick Shot #14 Answer
Answer: Fecal microbiota transplant or Bezlotoxumab or Fidaxomicin or
Switch ustekinumab to a JAK inhibitor after treatment of C. difficile or Referral to surgery to discuss colectomy
This patient is on her 3rd episode of C. difficile infection. For this recurrence, a preferred antibiotic strategy would be fidaxomicin (which she has never been treated with before) along with bezlotoxumab, a monoclonal antibody to C. difficile toxin B, which has been associated with reduction in risk of recurrent C. difficile. Fecal microbiota transplant should be considered even in the presence of active IBD, as efficacy for treatment of C. difficile remains high . A repeat course of vancomycin with taper along with bezlotoxumab could be considered if fidaxomicin is not available but would not a preferred option. The patient is not hospitalized with fulminant C. difficile infection and therefore combination therapy with metronidazole and vancomycin is not indicated. Additionally, her UC has been poorly controlled, with primary non-response to infliximab, and only partial response to ustekinumab, as demonstrated by persistent steroid dependence. Consideration can be given to switching to either tofacitinib or upadacitinib if she continues to have active UC after treatment of C. difficile, but referral to colorectal surgery should also be made as she may require colectomy to control her disease. Switching to adalimumab is not likely to benefit her with primary non-response to another anti-TNF.
- Allegretti JR, Kelly CR, Grinspan A, Mullish BH, Kassam Z, Fischer M. Outcomes of Fecal Microbiota Transplantation in Patients With Inflammatory Bowel Diseases and Recurrent Clostridioides difficile Infection. Gastroenterology. 2020 Nov;159(5):1982-1984. doi: 10.1053/j.gastro.2020.07.045. Epub 2020 Jul 30. PMID: 32738249.
- Allegretti JR, Kelly CR, Grinspan A, Mullish BH, Hurtado J, Carrellas M, Marcus J, Marchesi JR, McDonald JAK, Gerardin Y, Silverstein M, Pechlivanis A, Barker GF, Miguens Blanco J, Alexander JL, Gallagher KI, Pettee W, Phelps E, Nemes S, Sagi SV, Bohm M, Kassam Z, Fischer M. Inflammatory Bowel Disease Outcomes Following Fecal Microbiota Transplantation for Recurrent C. difficile Infection. Inflamm Bowel Dis. 2021 Aug 19;27(9):1371-1378. doi: 10.1093/ibd/izaa283. PMID: 33155639; PMCID: PMC8376126.