Sa2074 Title: Successful Treatment of Refractory Clostridium difficile Infection(Cdi) With Intestinal Microbiota Transplant (IMT) in Two Patients With Inflammatory Bowel Disease (IBD) and Its Effects on IBD

Abstract

C. difficile is responsible for 15-25% of antibiotic associated diarrhea and overall incidence of CDI is increasing including in patients with IBD. Among the various therapeutic modalities used for the treatment of IBD, only the use of steroids is found to be associated with increased risk of CDI; however the role of immunosuppressant use is controversial and the use of biologics has not been shown to have a clear association with development of CDI. Physicians are often reluctant to use immunosupression in the setting of CDI given fear of exacerbation of CDI, which in turn results in poor control of IBD. IMT has been demonstrated to be an effective treatment for refractory CDI. Methods: A 27-year-old woman with Crohns ileocolitis and refractory CDI for over one year had failed multiple prolonged tapering courses of vancomycin and probiotics. She had endoscopically proven active ileocolonic Crohns disease, which was not aggressively treated with immunosuppressants given her CDI. She had up to 25 stools a day and had lost 25 pounds, therefore she underwent successful IMT with approximately 250 g of donor stool from her mother, which was placed endoscopically into her ileum. Her diarrhea improved but did not completely resolve despite negative stool cultures two weeks post procedure. She was started on prednisone 40 mg a day, which was slowly tapered and started on Adalimumab concomitantly. She has been in clinical remission for over a year on 40 mg Adalimumab alone without recurrent CDI. A 39 yr old male with history of Ulcerative colitis diagnosed 15 ys ago with concomitant refractory CDI. He had been treated for CDI over 12 times in 15 years with multiple courses of flagyl, oral vancomycin and Rifaximin with no improvement. He continued to have 15 bowel movements per day. He was unable to tolerate adalimumab and azothioprine in the past and was felt to be high risk for steroids secondary to CDI. He underwent successful IMT on 2/2011 with donor stool from his mother. He has improved significantly since then and was started on high dose prednisone after negative C difficile testing with improvement of diarrhea. He has not had any relapse of CDI but still has evidence of active IBD on sigmoidoscopy five months post IMT. He has been maintained on 5 ASA drugs and a tapering course of steroids and being considered for colectomy. IMT with ileal infusion of the bacteriotherapy should be considered for treatment of refractory CDI in patients with concomitant IBD since it provides an opportunity to maximize therapy for IBD. A published case series of 6 patients demonstrated complete resolution of ulcerative colitis after IMT. Contrary to their study our experience with 2 patients showed resolution of CDI but no change in IBD with up to 1 year follow up. Further studies are needed to assess the role of IMT in the treatment of IBD.