Diagnosis, management, and prevention of infectious complications in inflammatory bowel disease: variations among Asian countries

Article information

Intest Res. 2023;21(3):277-279

Publication date (electronic) : 2023 July 27

doi : https://doi.org/10.5217/ir.2023.00076

Ji Eun Baek, Sung Wook Hwang

Department of Gastroenterology and Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Correspondence to Sung Wook Hwang, Department of Gastroenterology and Inflammatory Bowel Disease Center, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea. Tel: +82-2-3010-3195, Fax: +82-2-476-0824, E-mail: hsw903@gmail.com

Received 2023 June 29; Revised 2023 July 3; Accepted 2023 July 13.

Inflammatory bowel disease (IBD) is a chronic immune-mediated disorder of the gastrointestinal tract with a complicated pathogenesis, and its incidence and prevalence in Asian countries have been rapidly increasing [1]. With an improved understanding of the complex pathogenesis of IBD, there has been an expansion in the use of immunosuppressant therapy, along with an increasing use of biologics and small molecules, which makes patients with IBD at a higher risk for infectious complications [2,3]. Opportunistic infections in IBD are potentially serious, often difficult to identify, associated with severe morbidity or mortality, and difficult to treat effectively. The incidence rate of serious infections ranges between 10 and 100 events per 1,000 person-years, and the mortality rate of serious infections is approximately 4% among patients with IBD [4]. Considering the importance of infectious complications in IBD, the Western guidelines such as those of the European Crohn’s and Colitis Organisation (ECCO) provides valuable advice to clinicians for the management of infectious diseases in the IBD population [5]. These guidelines are focused on diagnostic and therapeutic interventions of various infectious complications and on vaccination strategies for immunosuppressed patients with IBD.

In the current issue of Intestinal Research, Jun et al. [6] investigated the differences in the diagnosis and management of the infectious complications in patients with IBD across Asian countries through a multinational online questionnaire survey. A total of 384 physicians including both IBD specialists (55.0%) and non-specialists from multiple countries or regions responded to questions regarding diagnosis (17 items), treatment (33 items), infection (22 items), and vaccination (15 items) for infectious diseases in real-world clinical practice. Most responders were from Korea (28.6%), China (25.8%), and Japan (24.2%). Although general similarities were noted across the Asian countries, variations in the approaches to infectious complications were observed, reflecting the different epidemiological perspectives of infections. In the treatment of Clostridium difficile infection (CDI), Korean (n = 70, 63.6%) and Chinese (n = 51, 51.5%) physicians preferred vancomycin, whereas Japanese (n = 62, 66.7%) physicians preferred metronidazole. For the treatment of latent tuberculosis infection, physicians in Korea (n = 88, 80.0%) and China (n = 46, 46.5%) preferred a 3-month course of isoniazid and rifampin, whereas physicians in Japan (n = 71, 76.3%) favored a 9-month course of isoniazid. Moreover, unlike Japanese physicians, Korean (n = 89, 80.9%) and Chinese physicians (n = 48, 48.5%) were likely to vaccinate patients lacking hepatitis B virus (HBV) surface antigen given the prevalence rates of HBV infection and chronic HBV hepatitis are higher in Korea and China than in Japan [7].

In a previous study, Yang et al. [8] also investigated infectious complications in Asian patients with IBD using a questionnaire survey. They found that most physicians considered tissue cytomegalovirus (CMV) DNA as an index for the diagnosis of CMV colitis. In addition, more than 80% of hospitals surveyed had the test for CMV immunohistochemistry. More than 60% of physicians agreed to routinely vaccinate patients with IBD if the hepatitis B surface antigen test was negative. Most physicians preferred metronidazole as the first choice for patients with CDI, followed by vancomycin [8]. However, of importance, this study only recruited 83 physicians and included 11 questionnaire items. In contrast, the study conducted by Jun et al. [6] included a large number of Asian physicians from various countries, and more than half of them were IBD specialists, although there might be inherent selection bias due to the low response rate (2.4%). The study by Jun et al. enhanced our understanding of real-world clinical practices around infectious complications associated with IBD in Asian countries. Consequently, the findings have the potential to motivate physicians to develop practical and appropriate guidelines for managing infectious complications in the Asian IBD population.

Well-organized Western guidelines on the diagnosis and management for infectious complications of IBD exist [5,9,10]. Clinical practice guidelines of CDI by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America recommend oral vancomycin as the first-line treatment for patients with an initial CDI episode [9]. The updated 2020 latent tuberculosis infection treatment guidelines prefer a short-course (3–4 months) of rifamycin-based treatment regimens over a longer-course (6–9 months) of isoniazid monotherapy [10]. The latest ECCO guidelines for IBD recommend that HBV serology should be performed for all patients with IBD and that they should be vaccinated against hepatitis B to achieve an anti-hepatitis B surface antibody level of > 10 IU/L [5]. Understanding the differences in the diagnosis and treatment of infectious complications between Asian and Western countries is crucial for management of Asian patients with IBD. According to the study by Jun et al., it is believed that each Asian country adheres to the latest guidelines customized to their specific circumstances. However, development of guidelines for infectious complications tailored to Asian patients with IBD is still warranted in the future.