1576 Use of Intravenous Immunoglobulin as a Treatment Adjunct for Refractory Clostridioides difficile Infection

Abstract

INTRODUCTION: Approximately 500,000 Clostridioides difficile infections (CDIs) occur annually in the USA. Recurrent CDI occurs in 20 to 30% patients with increasing rates of recurrence with each subsequent episode. Initial recurrences are treated with additional antibiotic regimens. Current treatment guidelines recommend fecal microbiota transplant (FMT) therapy after a 2nd recurrence treatment failure. Intravenous Immunoglobulin (IVIG) has been shown to be effective as a treatment adjunct in patients with CDI and hypogammaglobulinemia as well as in cases of severe and refractory CDI. Herein, we present a case of a patient with refractory CDI for two and a half years whose symptoms resolved after the addition of therapy with IVIG. CASE DESCRIPTION/METHODS: A 47 year old woman with refractory CDI for 2.5 years was admitted to our facility. She typically had 20 to 40 episodes of non-bloody diarrhea per day. Prior treatment courses included 4 fecal microbiota transplants, 13 oral vancomycin tapers, courses of metronidazole, 1 course of fidaxomicin, and colonic lavage with vancomycin installation, none of which provided relief for more than 1 week. Previously she had undergone EGD and colonoscopy with gastric, duodenal, colonic and terminal ileum biopsies which were unrevealing. Testing for celiac disease, TSH, ESR, CRP, gastrin level, Chromogranin A, vasoactive intestinal peptide 5-HIAA levels and stool osmolar gap were unremarkable. The patient had normal vital signs and had no major laboratory abnormalities. Total IgG was only slightly low at 667 mg/dL, normal range per hospital lab is 700-1600 mg/dL. Stool studies revealed persistent CDI. CT abdomen and pelvis w/o contrast showed no acute findings. She was started on Vancomycin 500 mg PO qid and diarrhea persisted. Colonoscopy with random biopsies revealed normal colonic mucosa and biopsies were negative. IVIG was added to enhance her immune response to refractory CDI. IVIG 20 g was administered daily for 2 days resulting in a dramatic decrease in diarrhea and the patient was discharged in good condition on hospital day 10. DISCUSSION: For our patient adjunctive treatment with IVIG led to resolution of infection and the avoidance of a total colectomy. We suggest consideration for incorporating IVIG therapy in difficult to manage CDI regardless of immunoglobulin status. A need remains for randomized control trials to better establish the optimal timing and dosing of IVIG in the treatment of CDI.