Do We Have an Opportunity to Avoid Opportunistic Infections in Asian Patients with Inflammatory Bowel Disease?

The risk of opportunistic infections among patients with inflammatory bowel disease (IBD) is an emerging issue of safety that continues to evolve along with the emergence of new mechanisms of therapy and new approaches to treatment. It is an important safety issue, as immunomodulators and biologic agents are being used more often and earlier during the disease course.1 In particular, biologic therapies have been associated with an increased risk of opportunistic infections.2,3 Even though immunosuppressive therapy is a major risk of opportunistic infections in patients with IBD, some risk factors are inherent to individual patients’ characteristics such as malnutrition, older age, congenital immunodeficiency, human immunodeficiency virus infection, chronic diseases, and diabetes mellitus.4 Therefore, the European Consensus guidelines on the prevention, diagnosis, and management of opportunistic infections detail a vaccination and systemic workup to consider before the commencement of immunosuppressive therapy, including steroids, azathioprine, 6‐mercaptopurine, and biologic agents.4

In this issue of Gut and Liver, Yang et al.5 investigated the current status of opportunistic infections in patients with IBD in Asia through a questionnaire-based multinational, multicenter study. The strengths of the current study include a multinational, multicenter survey in Asia, along with the multiple hospital systems for diagnosis, treatment, and prevention of IBD represented. In this study, surveys of 82 members of the Asian Organization for Crohn’s and Colitis from seven countries were analyzed, with all four regions represented.

Considering the different epidemiological perspectives of infection as well as the differences in resources between Asia and the West, there are gaps in approaches to diagnosis, treatment, and prevention of opportunistic infections in IBD. For example, due to the intermediate endemicity of hepatitis A and hepatitis B viruses in Korea compared with that in the United States and Western Europe, Park et al.6 suggested producing a guideline on the prevention and management of viral hepatitis in IBD. In the case of Clostridioides difficile infection (CDI), which can worsen underlying IBD, increase the risk of IBD treatment failure, and increase the risk of hospitalization and surgery,7 the symptoms of CDI overlap with those of an IBD flare making it difficult to diagnose. It makes it difficult to diagnose CDI in patients with IBD due to the lack of a uniform diagnostic tool for CDI.

Yang et al.5 have retrospectively assessed the state of opportunistic infections in Asian patients with IBD in the present scenario by using a questionnaire-based multicenter study. The authors’ analysis has reinforced our understanding of the increased risk for opportunistic infections among patients with IBD, as well as the presence of differences in diagnostic equipment for cytomegalovirus infection across countries. In addition, more than half of the members in Asian countries recommended hepatitis B virus vaccination when the hepatitis B surface antigen was tested negative, a rate slightly higher than that in the United States (around 50%).8 Also, it should be noted with caution that updated CDI guidelines published by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America in 2018 until now have recommended vancomycin as the first-line treatment for patients with an initial CDI episode.9 Even though, this survey was conducted in 2017, it did not reflect updated guidelines.

Each of these findings should further motivate clinicians to strive to optimize the guidelines to be more suitable for Asian patients through the development of health facilities, adjustment of medical insurance policies, and increased vaccination efforts.