Case Series: Efficacy of Polyclonal Intravenous Immunoglobulin for Refractory Clostridioides difficile Infection

Sophie A Ragan; Caitlin Doyle; Neha Datta; Heather Abdic; Mark H Wilcox; Ros Montgomery; Shanika A Crusz; Yashwant R Mahida; Tanya M Monaghan

doi:10.3390/antib13020026

Case Series: Efficacy of Polyclonal Intravenous Immunoglobulin for Refractory Clostridioides difficile Infection

Antibodies (Basel). 2024 Apr 1;13(2):26. doi: 10.3390/antib13020026.

Authors

Sophie A Ragan¹, Caitlin Doyle², Neha Datta², Heather Abdic¹, Mark H Wilcox^{3

4}, Ros Montgomery⁵, Shanika A Crusz⁶, Yashwant R Mahida^{7

8

9}, Tanya M Monaghan^{7

8

9}

Affiliations

¹ Department of Gastroenterology, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK.
² School of Medicine, University of Nottingham, Nottingham NG7 2RD, UK.
³ Healthcare Associated Infection Research Group, Leeds Institute of Medical Research, University of Leeds, Leeds LS9 7TF, UK.
⁴ Department of Microbiology, Leeds Teaching Hospitals, Leeds LS1 3EX, UK.
⁵ Infection and Prevention Control, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK.
⁶ Department of Microbiology, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK.
⁷ NIHR Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham NG7 2UH, UK.
⁸ Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham NG7 2UH, UK.
⁹ Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham NG7 2UH, UK.

Abstract

Background: Intravenous immunoglobulin (IVIg) for Clostridioides difficile infection (CDI) no longer features in treatment guidelines. However, IVIg is still used by some clinicians for severe or recurrent CDI (rCDI) cases. The main objective of this study was to investigate the efficacy of IVIg and to identify possible predictors of disease resolution post IVIg administration for patients with CDI.

Methods: This retrospective observational cohort study of patients ≥2 years old hospitalised with severe, relapsing, or rCDI treated with IVIg therapy was performed in a large UK tertiary hospital between April 2018 and March 2023. Scanned electronic notes from patient admissions and clinical reporting systems were used to collect relevant data.

Results: In total, 20/978 patients diagnosed with CDI over the 5-year study were treated with IVIg. Twelve (60%) had hospital-onset CDI. Eleven of the twenty patients (55%) responded to treatment, with a mean of 8.6 (SD 10.7) days to disease resolution. Sixteen (80%) patients were treated for severe CDI and four (20%) for rCDI (n = 3) and relapsing CDI (n = 1). There were no statistically significant differences in possible independent predictors of disease resolution post IVIg administration between groups. There was an average of 6.2 (4.9) days to IVIg administration after diagnosis with no difference between responders and non-responders (p = 0.88) and no further significant difference in additional indicators. Four (36%) of the responders were immunosuppressed compared to just one (11%) of the non-responders (p = 0.15). Six of the responders (two with recurrent and four with severe CDI) improved rapidly within 2 days, and three of these were immunosuppressed.

Conclusion: We observed disease resolution post IVIg therapy in over 50% of patients with refractory CDI. Our data also support a potential enhanced effect of IVIg in immunosuppressed individuals. Thus, the role of IVIg for CDI treatment, particularly in the immunosuppressed, warrants future case-control studies coupled to mechanistic investigations to improve care for this ongoing significant healthcare-associated infection.

Keywords: Clostridioides difficile infection; case series; intravenous immunoglobulin.

Grants and funding

This research received no external funding.