Vaccination in inflammatory bowel disease patients: attitudes, knowledge, and uptake.

BACKGROUND: Immunomodulators and biological agents, used to treat inflammatory bowel disease [IBD], are associated with an increased risk of infection, including vaccine-preventable infections. We assessed patient attitudes towards vaccination, knowledge of vaccine recommendations, and uptake of recommended vaccines. METHODS: Patients attending IBD clinics completed a self-administered, structured, paper-based questionnaire. We collected demographic data, medical and immunisation history, self-reported patient uptake, knowledge, and perceptions of childhood and adult vaccinations. RESULTS: The prevalence of treatment with biologicals, steroids, thiopurines, and methotrexate among the 300 respondents were 37.3%, 16.0%, 16.0%, and 5.7%, respectively. Self-reported vaccine completion was reported by 45.3% of patients. Vaccination uptake rates were 61.3% for influenza, 10.3% for pneumococcus, 61.0% for hepatitis B, 52.0% for hepatitis A, 26.0% for varicella, 20.7% for meningococcus, 5.3% for herpes zoster, and 11.0% for herpes papilloma virus [females only]. Significant predictors of vaccine completion were annual vaccination review by family physician (odds ratio [OR] = 1.82) or gastroenterologist [OR = 1.72], current steroid use [OR = 1.28], and current or prior treatment with biologicals [OR = 1.42]. The majority of patients reported that the primary responsibility to ensure vaccine completion lies with the patient [41.7%] and the family physician [32.3%]. Uncertainty about indications, fears of side effects, and concerns regarding vaccine safety were the most commonly reported reasons for non-uptake [22.0%, 20.7%, and 5.3%, respectively]. CONCLUSIONS: Uptake of recommended vaccines among IBD patients is suboptimal. Annual vaccination reviews by both family physician and gastroenterologist may improve vaccine uptake. Interventions targeted at improving vaccination uptake in IBD patients are needed.

Predictors and safety of venous thromboembolism prophylaxis among hospitalized inflammatory bowel disease patients.

INTRODUCTION: Inflammatory bowel disease (IBD) patients are at increased risk of venous thromboembolism (VTE) especially during hospitalization. We assessed the safety and predictors of VTE prophylaxis in this population. METHODS: We conducted a retrospective study of 974 IBD admissions between February 2010 and May 2012. We abstracted data on clinical characteristics, VTE prophylaxis and bleeding events, and conducted multivariate analysis to determine predictors of prophylaxis. RESULTS: Pharmacological VTE prophylaxis was administered to 80% of admissions; 63% were within 24h of admission. Patients on the surgical service (adjusted OR [aOR], 3.82; 95% CI: 2.00-7.29) and general medicine (aOR, 2.40; 95% CI: 1.39-4.12) were more likely to receive VTE prophylaxis compared to those on the gastroenterology service. Rectal bleeding on admission was associated with lower prophylaxis (aOR, 0.58; 95% CI: 0.35-0.97). The VTE prophylaxis rate increased from 47% to 73% (P<0.001) on non-surgical services with the introduction of a pharmacist advocate. The rates of major and minor bleeding were similar between patients who did and did not receive VTE prophylaxis (0.26 vs. 0 per 1000 person-days, P=0.7; 4.18 vs. 2.53 per 1000 person-days, P=0.4 respectively), and the major bleeding events (n=2) were post-operative. VTE prophylaxis was not associated with major postoperative bleeding (0.4% vs. 0%, P=0.96). CONCLUSIONS: VTE prophylaxis was more frequent on the surgical service, where standardized protocols exist. The introduction of a pharmacist advocate greatly increased VTE prophylaxis on the non-surgical services. Prophylactic anticoagulation is safe in IBD despite the presence of rectal bleeding on admission.

The utility of screening for asymptomatic lower extremity deep venous thrombosis during inflammatory bowel disease flares: a pilot study.

BACKGROUND: Asymptomatic deep vein thrombosis (DVT) occurs in up to 11% of medical inpatients. The incidence of asymptomatic DVT among patients with inflammatory bowel disease (IBD) is unknown but may be even higher. D-dimer is effective for DVT screening, but its utility has not been studied in the IBD population. METHODS: Hospitalized and ambulatory patients with IBD during flares were recruited between 2009 and 2011. Those with clinical symptoms of venous thromboembolism or previous venous thromboembolism were excluded. We determined the prevalence of DVT among asymptomatic subjects using lower extremity Doppler ultrasound and assessed the performance characteristics of the D-dimer in this high-risk study population. RESULTS: We enrolled 101 hospitalized and 49 ambulatory patients with IBD during active flares. There were no cases of proximal DVT detected by lower extremity Doppler ultrasound. The 95% confidence interval (CI) for the rate of proximal DVT was 0% to 2%. D-dimer was elevated in 60% of subjects without DVT, occurring more frequently among hospitalized than ambulatory subjects [89% versus 65%, P = 0.01; adjusted odds ratio (aOR), 4.16, 95% CI, 1.58-10.9]. Other predictors of elevated D-dimer were incremental decade in age (aOR, 1.97; 95% CI, 1.24-3.14); ulcerative colitis versus Crohn's disease diagnosis (aOR, 3.38; 95% CI, 1.29-8.84); and every 10-unit increase in C-reactive protein (aOR, 1.33; 95% CI, 1.09-1.62). CONCLUSION: From this pilot study, there appears to be low prevalence of asymptomatic DVTs among patients with IBD during flares. The high prevalence of elevated D-dimer in DVT-negative patients limits its utility in IBD.

Physicians' perceptions of risks and practices in venous thromboembolism prophylaxis in inflammatory bowel disease.

BACKGROUND: Hospitalized inflammatory bowel disease (IBD) patients are at a higher risk of venous thromboembolism (VTE). AIMS: We aimed to determine perceptions of VTE risks and self-reported practices regarding VTE prophylaxis in hospitalized IBD patients among American gastroenterologists. METHODS: Gastroenterologists who were members of the American Gastroenterological Association (AGA) and cared for IBD patients in the preceding 12 months were included. A survey assessed physicians' perceptions of VTE risks and their practices regarding VTE prophylaxis among IBD inpatients and other factors that may influence the decision to provide prophylaxis. RESULTS: A total of 135 eligible gastroenterologists responded to the survey, 77 % of whom practiced in academic settings. Most physicians (84%) reported having had IBD patients develop VTE. Only 67% cared for IBD patients in hospitals that had protocols for VTE prophylaxis, and 45% were aware of any published guidelines for VTE prophylaxis in hospitalized IBD patients. While only 7% believed that any rectal bleeding was a contraindication to VTE chemoprophylaxis in hospitalized IBD patients with flares, 14% never administered prophylaxis to IBD inpatients. A significant number of respondents felt that hospitalized IBD patients who were ambulatory (24%) or in remission (28%) did not require VTE prophylaxis. There was wide variation on recommendations for duration of anticoagulation for a first unprovoked VTE in an IBD patient. CONCLUSIONS: There is significant variation in reported practices for VTE prophylaxis in IBD patients among gastroenterologists. A more standardized approach to VTE prophylaxis should be implemented to improve health outcomes for IBD inpatients.

Patient awareness of extraintestinal manifestations of inflammatory bowel disease.

INTRODUCTION: Patient awareness of extraintestinal manifestations of inflammatory bowel diseases is important in improving patient understanding of their disease and health outcomes. We aim to characterize patient awareness of extraintestinal complications related to their disease. METHODS: A cross-sectional survey was administered from July 2011 to May 2012. All adult (>18 years) IBD patients attending gastroenterology clinics at a major tertiary teaching hospital (Mount Sinai Hospital, Toronto, ON, Canada) with a confirmed diagnosis of inflammatory bowel disease were invited to participate. RESULTS: A total of 299 patients participated: 177 Crohn's disease, 104 ulcerative colitis, and 18 IBD-unclassified. The vast majority of respondents obtained their information from their gastroenterologist (92%) and from the internet (78%). Most patients felt their inflammatory bowel disease knowledge was "very good" (34%) or "enough to get by" (54%). Most patients were aware of risk of colon cancer (75%), arthritis (77%), dermatological manifestations (49%), ocular inflammation (47%), and osteoporosis (53%). However, few patients were aware of venous thromboembolism (18%), nephrolithiasis (12%), or primary sclerosing cholangitis (20%). The majority of respondents were unsure of the signs and symptoms of venous thromboembolism, that the risk was increased during flares and hospitalizations, and that they require prophylaxis during an inflammatory bowel disease-related hospitalization. CONCLUSION: Although the majority of respondents demonstrated awareness of most extraintestinal manifestations, few realized that venous thromboembolism was a life-threatening systemic complication of inflammatory bowel disease. Greater knowledge of venous thromboembolism would enable patients to more promptly seek potentially life-saving intervention.

Survey of perceptions and practices among Canadian gastroenterologists regarding the prevention of venous thromboembolism for hospitalized inflammatory bowel disease patients.

BACKGROUND: Patients with inflammatory bowel disease (IBD) who are hospitalized with disease flares are known to be at an increased risk of venous thromboembolism (VTE). This is a preventable complication; however, there is currently no standardized approach to the prevention and management of VTE. OBJECTIVES: To characterize the opinions and general prophylaxis patterns of Canadian gastroenterologists and IBD experts. METHODS: A survey questionnaire was sent to Canadian gastroenterologists affiliated with a medical school or IBD referral centre. Participants were required to be practicing physicians who had completed all of their training and had been involved in the care of IBD patients within the previous 12 months. Various clinical scenarios were presented and demographic data were solicited. RESULTS: The majority of respondents were practicing in an academic setting (95%) and considered themselves to be IBD experts or subspecialists (71%). Eighty-three per cent reported providing VTE prophylaxis most, if not all of the time, and most (96%) used pharmacological prophylaxis alone, usually heparin or one of its analogues. There was less consistency among respondents with respect to whether IBD patients in remission, but admitted for another condition, should be given prophylaxis. There was also less agreement regarding the duration of anticoagulation in patients with confirmed VTE. CONCLUSION: There was a general consensus among academic gastroenterologists that IBD inpatients are at an increased risk for VTE and would benefit from VTE prophylaxis. However, areas of uncertainty still exist and the IBD community would benefit from evidence-based clinical practice guidelines to standardize the management of this important problem.

Prevalence and predictors of MRSA, ESBL, and VRE colonization in the ambulatory IBD population.

BACKGROUND AND AIMS: Inflammatory bowel disease (IBD) patients may be at increased risk of acquiring antibiotic-resistant organisms (ARO). We sought to determine the prevalence of colonization of methicillin-resistant Staphylococcus aureus (MRSA), Enterobacteriaceae containing extended spectrum beta-lactamases (ESBL), and vancomycin-resistant enterococi (VRE) among ambulatory IBD patients. METHODS: We recruited consecutive IBD patients from clinics (n=306) and 3 groups of non-IBD controls from our colon cancer screening program (n=67), the family medicine clinic (n=190); and the emergency department (n=428) from the same medical center in Toronto. We obtained nasal and rectal swabs for MRSA, ESBL, and VRE and ascertained risk factors for colonization. RESULTS: Compared to non-IBD controls, IBD patients had similar prevalence of colonization with MRSA (1.5% vs. 1.6%), VRE (0% vs. 0%), and ESBL (9.0 vs. 11.1%). Antibiotic use in the prior 3 months was a risk factor for MRSA (OR, 3.07; 95% CI: 1.10-8.54), particularly metronidazole. Moreover, gastric acid suppression was associated with increased risk of MRSA colonization (adjusted OR, 7.12; 95% CI: 1.07-47.4). Predictive risk factors for ESBL included hospitalization in the past 12 months (OR, 2.04, 95% CI: 1.05-3.95); treatment with antibiotics it the past 3 months (OR, 2.66; 95% CI: 1.37-5.18), particularly prior treatment with vancomycin or cephalosporins. CONCLUSIONS: Ambulatory IBD patients have similar prevalence of MRSA, ESBL and VRE compared to non-IBD controls. This finding suggests that the increased MRSA and VRE prevalence observed in hospitalized IBD patients is acquired in-hospital rather than in the outpatient setting.