International consensus report highlights need for improved management of CDI in IBD patients

Results from an international consensus project involving a multidisciplinary group of clinicians have been presented at the 26^th European Congress of Clinical Microbiology and Infectious Diseases (ECCMID) 2016.

A current lack of data on outcomes in patients with IBD who have CDI means that appropriate choice of treatment strategy can be unclear. The consensus examines the issues impacting clinical professionals working with CDI and aims to understand the perceptions and attitudes of key stakeholders regarding best practice in the management of CDI in patients with IBD.¹

CDI is associated with high-mortality² and cost burden.³ It causes or contributes to death in 2 out of 5 people who die within three months of diagnosis² and patients who acquire CDI are estimated to stay in hospital for an extra one to three weeks^4,5 at an additional cost of up to €14,000 per patient.⁶ Research has shown that IBD patients with co-existent CDI are hospitalised for substantially longer, with a median length of stay of 26 days compared with just five days for patients with IBD alone.⁷ Overall, CDI is estimated to cost the EU €3 billion per annum and this cost is expected to almost double over the next four decades.³

“We know that CDI has important consequences for patients and healthcare systems, including excess morbidity, mortality and length of hospitalisation. These consequences are most pronounced in vulnerable patients, including those with inflammatory bowel disease”, commented study author Professor Mark Wilcox, Professor of Medical Microbiology, Leeds Teaching Hospitals & University of Leeds.

Based on the consensus scores of 426 international healthcare professionals, including infectious disease specialists, microbiologists, and gastroenterologists, recommendations have been suggested to further develop and improve the management of CDI in patients with IBD;¹

• The need for a treatment strategy for CDI in IBD that is driven by risk factors for poor outcome rather than one solely defined by severity of disease
•  The need for clarity regarding clinical definitions of recurrent CDI and the need for a uniformly accepted definition of recurrent CDI in IBD patients
• The utility of a common approach to CDI in IBD in helping to reduce variance in clinical practice between specialties and, in order to achieve this, the need for clinicians to be familiar with the role and responsibilities of other specialties in managing CDI in IBD
• The need for higher quality evidence to inform future CDI guidelines, including clarity regarding the adjustment of immunosuppression in patients with IBD
• The need for further data to define the place of faecal microbiota transplant in CDI patients with IBD
• Recognition of CDI risk factors was low amongst clinicians, indicating the need for a model for scoring symptom severity.

Clinicians were asked to rate their agreement with 27 statements. Statements were submitted to respondents at conferences and congresses and, based on the resultant consensus scoring, recommendations were developed. Levels of agreement exceeded the 75% threshold for consensus for 17 out of the 27 statements, indicating strong support for the majority. Differences were observed between the perceptions of microbiologists and gastroenterologists as well as between countries.¹

“The survey showed that members from all participating medical disciplines equally recognise the importance of infections with Clostridium difficile as critical events in the course of inflammatory bowel disease. It was astonishing to find, however, that the diagnostic and treatment strategies vary significantly between different specialists”, said Lead author, Professor Dr med Andreas Stallmach, Department of Internal Medicine IV, Jena University Hospital. “The results of this study underline that we urgently need interdisciplinary controlled studies aiming to optimise and harmonise treatment strategies for C. difficile in patients with inflammatory bowel disease.”

This project builds on a previous EU consensus report published in 2015 that put forward recommendations for the development of CDI services to help reduce transmission and recurrence and to ensure that appropriate diagnosis and treatment strategies are applied across all healthcare settings.⁸

References

1. Stallmach A et al. IBD and CDI: The contrasting views of different clinical professionals. Abstract presented at ECCMID 2016.
2. Bauer MP, Notermans DW, van Benthem BH, et al. Clostridium difficile infection in Europe: a hospital-based survey. Lancet. 2011;377:63–73.
3. Jones AM, Kuijper EJ, Wilcox MH. Clostridium difficile: a European perspective. J Infect. 2013; 66(2):115-28.
4. Wilcox MH et al. Financial burden of hospital-acquired Clostridium difficile infection. J Hosp Infect. 1996;34:23–30.10.
5. Dubberke ER et al. Review of a current literature on the economic burden of Clostridium difficile infection. Infect Control Hosp Epidemiol. 2009;30:57-66.
6. Magalini S et al. An economic evaluation of Clostridium difficile infection management in an Italian hospital environment. Eur Rev Med Pharmacol Sci. 2012;16:2136–41.
7. Jen MH et al. Increased health burden associated with Clostridium difficile diarrhoea in patients with inflammatory bowel disease. Alimentary pharmacology & therapeutics. 33.12 (2011): 1322-1331.
8. Aguado JM et al. Highlighting clinical needs in Clostridium difficile infection: the views of European healthcare professionals at the front line. Journal of Hospital Infection. 90.2 (2015): 117-125.