In patients with IBD who develop Clostridium difficile infection, how does escalating corticosteroid therapy compare with modifying biologic or immunomodulator regimens for the likelihood of colon surgery and other adverse outcomes

In IBD patients with C. difficile infection, escalating or adding corticosteroids during the infection was associated with a nearly 6-fold higher risk of colon surgery within 1 year (OR 5.94; 95% CI 2.03–17.44), whereas modifying biologic or immunomodulator regimens was not associated with differences in colon surgery, CDI recurrence, or future IBD exacerbation ¹. Modifying the corticosteroid regimen itself did not affect CDI recurrence or risk of future IBD exacerbation ¹. ¹

What is known: - Corticosteroid escalation was a positive predictor of colon surgery within 1 year, and colon surgery was more common in patients with steroid escalation than in those continued at same dose or not on steroids. ¹ - Adverse outcomes did not differ with CDI antibiotic regimens or with biologic or immunomodulator regimen modification. ¹ - Immunomodulator de-escalation did not influence the increased colon surgery incidence in the corticosteroid escalation cohort on multivariate analysis; steroids were most commonly added/escalated while biologics/5-ASAs were most commonly de-escalated. ¹ - Type of CDI treatment (vancomycin, metronidazole, or both) did not influence rates of colon surgery, CDI recurrence, or IBD exacerbation. ¹

What is unknown / caveats: - Another cited study failed to show a clear association between corticosteroid use and subsequent IBD exacerbations in CDI patients ¹ - Single retrospective cohort (137 patients, only 4 with indeterminate colitis) - Association may reflect confounding by indication. Sicker patients got steroids - Cannot establish whether steroid escalation caused surgery or marked more severe disease - Because more severe CDI was associated with both steroid escalation and immunomodulator de-escalation, it is unclear whether treatment changes drove outcomes or reflected disease severity.

## References

1. Solanky D, Pardi DS, Loftus EV, Khanna S. Colon Surgery Risk With Corticosteroids Versus Immunomodulators or Biologics in Inflammatory Bowel Disease Patients With Clostridium difficile Infection. Inflamm Bowel Dis. 2019;25(3):610-619. PMID: 30260451.

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