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P402 Is co-trimoxazole prophylaxis necessary for Inflammatory Bowel Disease patients receiving triple immunosuppression?

Phillips, G.(1);Moore-Gillan, C.(1);Mohamed, Z.(1);Mikin, P.(1);Peake, S.(1);Hicks, L.(1);

(1)Imperial College London NHS Trust, Gastroenterology, London, United Kingdom

Background

ECCO Guidelines (1) advocate Co-trimoxazole (TMP/SMX) prophylaxis against Pneumocystis jirovecii for patients with inflammatory bowel disease (IBD) on triple immunosuppression, although the evidence level is low and based on non-IBD patient data (2). We assessed adherence to this guidance and frequency of infection events among IBD patients at Imperial College Healthcare NHS Trust, London, UK. 

Methods

Eligible patients were defined as those on a combination of 2 immunosuppressants (with one of those being a biologic) between December 2017 to December 2020, who received a course of high dose steroids (≥20mg prednisolone).  Patient demographics, IBD treatment, TMP/SMX prophylaxis and infections (including hospitalisation) developed within 30-days of starting high dose steroids were recorded retrospectively using the hospital electronic patient records.

Results

In the cohort of 247 patients on concomitant biologic and immunosuppression dual therapy 176/247 (71%) were ≤ 49 years old and 136/247 (55%) were male. Over the three year observation period, 333 individual thiopurine-biologic combinations were prescribed; Of the biologics 157/333 (47%) were infliximab, 91/333 (27%) adalimumab, 50/333 (15%) vedolizumab, 27/333 (8%) ustekinumab and 8/333 tofacitinib (3%). All received azathioprine or 6MP concurrently. 

Steroids were prescribed on 75 occasions for 50 (20%) patients. Of 28/75 (37%) prescriptions where TMP/SMX was co-prescribed 4/28 (14%) developed infections with 1/28 (4%) requiring hospitalisation. There were no respiratory infections in this group. Of the 47/75 (63%) where TMP/SMX was not prescribed 7/47 (15%) developed infections (4/47 respiratory, 2/47 skin or bone, 2/47 [MZ1] gastrointestinal infections). One patient had 2 infections. The hospitalisation rate was 2/47 (4%). There were no confirmed cases of Pneumocystis jirovecii in either group.


Conclusion

Existing evidence for TMP/SMX prophylaxis in this setting is limited and is reflected in the varied clinical practice observed. However, no difference in clinically significant infection rates among individuals with and without TMP/SMX prophylaxis was observed in our setting. Further data are required to validate the utility of antibiotic prophylaxis in severely immunosuppressed IBD cohorts to better guide its use. 

(1)   Rahier et al, Second European evidence-based consensus on the prevention, diagnosis and management of opportunistic infections in inflammatory bowel disease; JCC 2014
(2)   DiRienzo et al, Efficacy of trimethoprim-sulfamethoxazole for the prevention of bacterial infections in a randomized prophylaxis trial of patients with advanced HIV infection. AIDS Res Hum Retroviruses 2002

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