Case 15.5
What do you recommend as the next step for this person with IBD who has now had three recurrences of CDI?
Vancomycin 500 mg 4x daily for 10 days
A higher dose of vancomycin is unlikely to have additional efficacy after failure of standard dosed and pulse/taper regimens of vancomycin. A higher dose is indicated for fulminant CDI, which is not evident here.
Switch biologic agent to a different anti-TNF
There is no evidence of significant UC activity, therefore switching to a different biologic is not appropriate. Her ongoing symptoms are more likely due to untreated recurrent CDI.
Fecal Microbiota Transplant
Correct! Guidelines support fecal microbiota transplant for recurrent C. difficile infection.
Additional course of antibiotics with or without bezlotoxumab
Guidelines favor FMT where available for patients presenting with a third or subsequent recurrence of CDI. If FMT is not available, another course of antibiotics using one of the regimens listed on the prior page that has not previously been tried would be reasonable.
You mention the possibility of fecal microbiota transplant (FMT), and she is concerned that this could worsen her IBD.
Which of the following is true about FMT in persons with IBD?
FMT is the only option for treating CDI at this point
She has a very high risk of worsening of UC after FMT therapy
Flare of UC post-FMT has been reported but occurs in a minority of patient
There is no risk of IBD flare with FMT therapy