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recent health-care contact, antibiotic use, hospitalization) concomitant treatment for presumed C. Because it is often difficult to distinguish the effect of CDI independent from that of underlying IBD and because the data reporting worse outcomes in patients on combination immunosuppression and antibiotic therapy (153,154) have several limitations, we recommend that ongoing immunosuppression be continued at existing doses in IBD-CDI patients.

One study has suggested that reducing the dose of systemic corticosteroids may help reduce the need for colectomy (149), but there are no prospective studies to confirm or refute this. Escalation of the corticosteroid dose or initiation of anti-TNF (anti-tumor necrosis factor) therapy in patients with a positive CDI probably should be avoided for 72 h after initiating therapy for CDI. In patients with severe disease, early co-management with surgeons is essential as patients with fulminant colitis may require emergent subtotal colectomy.