Mistakes in... 2022 - 38

ueg education
Mistakes in... 2022
Mistakes in opportunistic infections and vaccinations in IBD and
how to avoid them
Julien Kirchgesner and Paul McLellan
The introduction and general use of new immunosuppressive agents, including
biologic agents and small molecules, has revolutionised the therapeutic management
of inflammatory bowel disease (IBD). Such immunosuppression may expose patients
to opportunistic infections, which can be challenging to recognise. These infections are
crucial due to their association with morbidity or mortality and the challenges
regarding effective treatment. New evidence in this field and vaccination strategies
for immunosuppressed IBD patients led to updated European Crohn's and Colitis
Organization (ECCO) guidelines in 2021.
Here we discuss the errors to avoid when managing the risk of opportunistic
infections in IBD patients. The discussion is based on evidence, whenever possible,
and our clinical experience.
Mistake 1 Not screening for viral
infections at IBD diagnosis
Serologic screening for Hepatitis A (HAV),
Hepatitis B (HBV), Hepatitis C (HCV), Human
Immunodeficiency Virus (HIV), Epstein-Barr virus
(EBV) and Cytomegalovirus (CMV) is recommended
in all patients with IBD during the diagnosis.
Serologic screening for Varicella zoster (VZV) and
Measles virus is only recommended in the absence
of past infection or vaccination documentation.
Serologic screening at an early stage of the disease
allows for a vaccination strategy before exposure
to immunosuppressive therapy, which has been
associated with suboptimal serological responses
to various vaccines (see Table 1).1
Mistake 2 Not vaccinating patients
for pneumococcal disease and
influenza
Pneumococcal vaccination should be
recommended for all patients with IBD
before immunosuppressive therapy since IBD
has been associated with an increased risk of
pneumococcal infection. Pneumococcal
vaccines with both the 13-valent Pneumococcal
Conjugate Vaccine (PCV13) and the 23-valent
Pneumococcal Polysaccharide Vaccine
(PPSV23) are also recommended, with a
single revaccination after five years for the
polysaccharide vaccine. Annual Influenza
vaccination should be administered to patients
under immunosuppressive therapy according to
national guidelines.2
© UEG 2022 Kirchgesner and McLellan
Cite this article as: Kirchgesner J and McLellan P. Mistakes in
opportunistic infections and vaccinations in IBD and how to avoid
them. UEG Education 2022; 22: 26-28.
Vaccine strategy
General population vaccines
At diagnosis of IBD
Follow a routine vaccination program including age-specific vaccines
(i.e., Influenza, Zoster) according to country specific guidelines
VZV vaccine (if no history of chickenpox and negative VZV serology,
contraindicated during immunosuppressive therapy)
Hepatitis B (if hepatitis B virus serology is negative)
Influenza (trivalent inactivated)
Human papilloma virus
Before advanced therapies
Annually
Discretionary travel vaccines
Pneumococcal vaccines
Influenza (trivalent, inactivated)
Booster Pneumococcal polysaccharide vaccine (5 years)
Live vaccines (e.g., Yellow fever, oral Poliomyelitis) are contraindicated
during immunosuppressive therapy
Table 1 | Vaccination strategy in patients With IBD
Mistake 3 Not checking for Tuberculosis
infection before advanced therapies
Among advanced therapies (biologics and small
molecules), anti-TNF agents and Janus kinase
(JAK) inhibitors have been found to make more
patients susceptible to tuberculosis infection.
The accuracy of interferon-gamma release
assays (IGRAs) and tuberculin skin tests
in diagnosing latent tuberculosis in
immunocompromised IBD patients, notably
patients exposed to corticosteroids, is lower
than in immunocompetent adults. For this
reason, testing should be ideally performed at
the time of diagnosis. IGRAs should be preferred
over tuberculin skin tests (TSTs), as there is no
cross-reactivity with the Bacillus Calmette-Guerin
Julien Kirchgesner is Associate Professor at the Department of
Gastroenterology, Saint Antoine Hospital, AP-HP, Paris, France.
Paul McLellan is Assistant Professor at the Department of
Gastroenterology, Saint Antoine Hospital, AP-HP, Paris,
France.
26
vaccine and IGRAs are more likely to be positive
in case of recent tuberculosis infection compared
to TSTs.3
Patients at risk for tuberculosis infection,
notably those living or travelling in intermediate
or high tuberculosis incidence areas, should be
re-screened before initiation of advanced
therapy as latent TB might have been acquired.
A chest X-ray must also be performed.
Anti-TNF therapy should be postponed, and
antituberculosis treatment should be given
according to national guidelines whenever latent
or active tuberculosis is suspected.
Intestinal tuberculosis and Crohn's disease
can have similar clinical and endoscopic
presentations. In countries where tuberculosis
is endemic, tuberculosis infection must be ruled
Illustrations: J. Shadwell.
Correspondence to: julien.kirchgesner@gmx.com.
Conflicts of interest: JK acknowledges receiving lectures fees from
Gilead, Roche and Pfizer. PM declares no conflicts of interest.
Published online: September 15, 2022.
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