Society: AGA

BACKGROUND: Perianal fistulizing complications (PFC) of Crohn’s disease (CD) are highly morbid and difficult to treat. Despite the advent of biologic medications, antibiotics remain a mainstay of PFC treatment. The optimal antibiotic regimen for PFC has not been determined, and extent of antibiotic use has not been quantified. To develop benchmarks for antibiotic stewardship, we aimed to characterize antibiotic utilization for PFC in a large multicenter cohort.
METHODS: We identified pediatric patients ≤21yr at CD diagnosis and enrolled in the ImproveCareNow Network (ICN) within 30 days of CD diagnosis (2007-2018), and with ≥3 outpatient visits. ICN is a multicenter, multidisciplinary pediatric IBD quality improvement collaborative. The ICN registry includes prospectively collected data from outpatient pediatric gastroenterology visits. Medications are recorded in the registry only at outpatient visits; therefore, use between visits including hospitalization are unavailable. Antibiotics in the registry include ciprofloxacin, metronidazole, and rifaximin. Duration of antibiotic use was approximated using the number of visits with an antibiotic use. We evaluated the presence of a PFC and timing of medication initiation. For patients with PFC, we only included antibiotics after PFC for maximum 2yr, for non-PFC patients all antibiotics were included. Descriptive statistics are presented.
RESULTS: We identified 5,720 patients from 80 ICN sites (median age 13.5yr, 40.5% female, 18.7% non-White), among whom 1,023 (30.7%) developed PFC. There were no differences in PFC rate by gender, age at diagnosis, race, or insurance. Patients with PFC were more than 2.5x as likely as those without PFC to receive antibiotics (27.5% vs. 11.1%, p<0.001). Most with PFC (58.9%) had multiple visits with antibiotics (up to 18 visits) within 2yr after PFC. Of those with PFC, males were more likely than females to receive antibiotics (29.7% vs 24.2%, p=0.010). There were no differences in antibiotic use by age at diagnosis or race. Patients with commercial insurance were less likely than those without commercial insurance to receive antibiotics after PFC (26.4% vs. 35.3%, p=0.003). Variation in antibiotic use after PFC ranged from 0 to 53.8% across ICN sites. Among patients treated with antibiotics, multiple simultaneous antibiotics (e.g., ciprofloxacin + metronidazole) were used more than 3x as often by those with PFC compared to those without PFC (75.6% vs. 24.4%, p<0.001).
CONCLUSIONS: One in four children with Crohn’s disease are prescribed antibiotics as outpatients after PFC development. Over half have multiple visits with antibiotics within the first 2 years after PFC, and multiple simultaneous antibiotics are used in ¾ of the patients with PFC. There is a large variation in antibiotic use between the centers and antibiotic stewardship in this population is sorely needed.

Alison Tribble

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