Background Premedications are commonly given to inflammatory bowel disease (IBD) patients prior to intravenous infliximab administration. We aimed to (1) describe practice variability; and (2) determine clinician rationale for premedicating IBD patients prior to infliximab administration. Methods We developed a cross-sectional electronic survey after comprehensive literature review to assess practice variability and clinician rationale for premedication use prior to infliximab. An optional post-survey quiz assessed clinicians’ understanding of available literature. The survey was distributed through members-only NASPGHAN and Crohn’s and Colitis Foundation of America (CCFA) listservs and American Gastroenterological Association (AGA) and American College of Gastroenterology (ACG) web-based discussion boards. Results 379 unique respondents with a 93.3% survey completion rate comprised 331 (87%) and 45 (12%) pediatric and adult gastroenterologists. Among numerous options for premedications, acetaminophen (66%) and diphenhydramine (64%) were most often given prior to each infliximab infusion. Only 20% did not routinely use premedications. There was heterogeneity of premedication use between gastroenterologists within the same clinical practice. Of 328 (87%) respondents who completed the knowledge assessment quiz, only 18% identified the association of diphenhydramine use with increased reaction. Conclusion There is high inter- and intra-practice variability for premedication use prior to infliximab administration. Clinician rationale for premedicating patients appears to be driven by individual preference or group practice habit. Improved knowledge of the evidence may assist in decreasing over-use of premedications, particularly diphenhydramine.

In this prospective cohort study, we examine the feasibility of a protocol to optimize microbiota for fecal microbiota transplantation (FMT). Donor stool metrics generally accepted as markers of gut health were used to select a stool donor based on superior microbial diversity, balanced constitution of Bacteroidetes versus Firmicutes and high concentration of fecal butyrate. Selected donor microbiota was then administered via FMT. A total of 10 patients with median age of 12 years with recurrent Clostridium difficile infection received the intervention. The rate of recurrence-free resolution with 1-2 FMTs was 100% at Week 10. With a single FMT, 80% of patients cleared Clostridium difficile infection without recurrence, whereas 20% of patients required a single re-treatment. No serious adverse events occurred. Microbiota sequencing revealed that recipients' gut microbiota phylogenic diversity increased by 72-hours post-transplantation, with sustainment over 10-week follow-up. This study highlights the feasibility of purposefully selecting the most ideal microbiota for transplantation.

In this report, we describe incremental changes, over a two year period at a single center with the administration of maintenance infliximab infusions. Given practice-driven changes consisting of one-hour infusions and omission of pre-medications, we aimed to investigate if these changes contributed to severe infusion reactions. We reviewed approximately 900infliximab infusions in a pediatric ambulatory infusion center from January 1, 2014-December 31, 2015 for severe adverse reactions requiring either rescue epinephrine or a code blue or ‘rapid response’ activation. In 2015, these practice changes resulted in a 51% decrease in total infusion hours (1281 to 630 infusion hours), despite a 9% increase in total number of infusions. No increase in severe adverse events associated with either rapid 1-hour infusion or omission of pre-medications. Our findings highlight a quality-improvement opportunity to standardize infliximab infusions to streamline care in an ambulatory setting.

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