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.

INTRODUCTION: Eosinophilic esophagitis (EoE) is a chronic, allergen-mediated clinicopathologic disease affecting all ages. While the differences between pediatric and adult onset EoE has been well documented, little is known about the differences within the pediatric onset EoE. Herein, we investigated if clinical features are distinct for early childhood onset EoE (eo-EoE; < 5 years) when compared to late childhood onset EoE (lo-EoE; 5-18 years).
METHODS: We reviewed medical records of 269 children (≤18 years) newly diagnosed with EoE at Monroe Carell Jr. Children’s Hospital at Vanderbilt between May 2017 and October 2022. EoE was defined per the 2011 Consensus Guidelines. Their socio-demographic data, growth parameters, clinical presentation, allergic comorbidities, family history, esophagogastroduodenoscopy (EGD) findings rated per the endoscopic reference scoring system (EREFS), and esophageal histology (peak eosinophil count, and presence or absence of basal zone hyperplasia, eosinophilic microabscess, and lamina propria fibrosis) were extracted for analysis. The eo-EoE and lo-EoE groups were matched for gender, race, and ethnicity. Chi-squared and Fisher Exact tests were used for categorical data and paired t-tests for continuous variables.
RESULTS: In all, 50 children were in the eo-EoE group and 58 children were in the lo-EoE group. The mean (SD) age of the eo-EoE group was 1.86 (1.16) years and the lo-EoE group was 12.4 (3.33) years of age. Z-score for age (weight/length if age < 2 years or body mass index if age ≥ 2 years) was significantly lower for eo-EoE compared to lo-EoE [0.01 (1.48) vs. 0.80 (1.25); P < 0.004]. The eo-EoE group had significantly higher rates of eczema (54.0% vs. 17.2%; P<0.001), weight concerns (36.0% vs. 10.3%; P = 0.002), and feeding difficulties (30.0% vs. 0.0%; P < 0.001) compared to lo-EoE group. On the other hand, children in the lo-EoE group were more likely to present with abdominal pain (3.0% vs. 21.0%; P < 0.001) compared to children in the eo-EoE group. The total EREFS scores were lower in the eo-EoE group compared to the lo-EoE group [1.34 (0.96) vs 2.00 (1.28); P=0.006], and they were less likely to have edema (24.0% vs. 50.0%, P = 0.009). There were no differences between the groups with regards to family history of EoE or atopy and histologic findings.
CONCLUSIONS: Clinical features such as feeding difficulties, atopic co-morbidities, growth faltering, and EoE-relevant endoscopic abnormalities can distinguish children with eo-EoE from lo-EoE even after accounting for gender, race, and ethnicity. These results deepen our understanding of the pediatric EoE. Further investigation is needed to understand why the presentation of eo-EoE differs from lo-EoE and why the endoscopic findings are relatively mild in eo-EoE, despite no difference in histologic findings.

Background: Delayed diagnosis of inflammatory bowel disease (IBD) is associated with prolonged symptom burden and worse long-term outcomes. Racial and ethnic disparities and social barriers are commonplace in healthcare; however, the extent that these factors are associated with diagnostic delay are largely unknown.

Objective: To evaluate whether race, ethnicity, disease type, and social factors are associated with delayed diagnosis of pediatric IBD.

Methods: We recruited pediatric patients diagnosed with IBD in the preceding 6 months at 23 U.S. sites from 2019-2022. Parents/guardians reported race, ethnicity, birth country, gender, household income, insurance type, travel time to treatment center as well as the length of time between symptom onset and IBD diagnosis. Parents/guardians also completed a health literacy measure (the Newest Vital Sign) and the Health Care System Distrust scale. We conducted bivariate and multivariable analyses using generalized estimating equations to evaluate associations between these factors and time to diagnosis defined as ≤ 60 days, 61 to 180 days, 181-365 days and >365 days.

Results: We enrolled 843 patients (mean age at diagnosis 13.2 years, 51% male, 54% Crohn’s disease (CD), 33% ulcerative colitis (UC), 8% Hispanic, 71% non-White). Overall, the mean time to diagnosis was 263 days (median 180). Bivariate associations between measured variables and time to diagnosis are provided in Table 1. After adjustment, associations with longer time to diagnosis included CD vs UC (OR 2.5, 95% CI 1.9-3.3) and longer travel time to clinic [(> 1 hour (OR 1.7, 95% CI 1.2-2.3), > 2 hours (OR 1.6, 95% CI 1.1-2.4) each vs <30 minute]. Race, ethnicity, birth country, gender, parent education, household income, insurance type, health literacy, and health system distrust were not associated with time to diagnosis.

Conclusions: Consistent with prior literature, children with CD experienced longer time to diagnosis than those with UC. Distance to IBD center appears to be a barrier to timely diagnosis, suggesting an urgent need to evaluate innovative models to provide timely and efficient care for communities disproportionately affected by longer travel times. Reassuringly, our findings demonstrate equitable access to IBD diagnostic care across racial and ethnic groups.

Michael Kappelman

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