Management of Hospitalized Patients with Inflammatory Bowel Disease and CMV Infection or Clostridium Difficile Infection

Patients with inflammatory bowel disease (IBD) are at increased risk of developing Clostridioides difficile (C. difficile) and cytomegalovirus (CMV) infection. Although symptoms in both conditions often overlap with those of IBD, it is essential to diagnose them quickly as they can both lead to adverse outcomes such as increased risk of colectomy or death. C. difficile should be ruled out in all patients hospitalized with a flare using a stool-based two-step testing algorithm. If C. difficile infection is present, oral vancomycin is the treatment of choice. Among patients with severe or steroid-refractory colitis, a sigmoidoscopy with biopsies to rule out CMV should be performed early in the hospital admission. Although the optimal diagnostic method for CMV is still unclear, histopathology with immunohistochemistry possibly combined with blood CMV DNA testing is preferred. CMV colitis should be treated with intravenous ganciclovir initially, which can then be transitioned to oral valganciclovir for a total of 2-3 weeks. The management of immunosuppressive therapy in the setting of superimposed C. difficile or CMV infection should be individualized, but both the underlying IBD and infection have to be aggressively treated.