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Inflammatory bowel disease (IBD) is a chronic relapsing and remitting disease that is increasing in incidence throughout the Western world.1 Although multiple questions regarding its aetiology remain, immunosuppressive therapy is used as the mainstream treatment in both adults and children.2 Concerns have been raised regarding theirsafety and potential side effects on a short-term and long-term basis. Several databases have been initiated to evaluate this effect. Based on recent reports of an increased incidence of hepatosplenic T cell lymphoma in young male IBD patients receiving a combination therapy of anti-tumour necrosis factor antibodies and azathioprine (Aza), malignancy is the most dreaded complication.3 Nevertheless, as in all immunosuppressed patients, opportunistic infections are an important caveat.4 Here, we would like to focus on the risk for opportunistic infections due to immunosuppression in paediatric IBD and various aspects of prevention. Unfortunately, because paediatric data on this topic are scarce, data from adult IBD and rheumatoid arthritis populations are included.
Immunosuppressed or not immunosuppressed?
Any patient receiving a daily dose of 20 mg prednisone or more for 14 days should be considered immunosuppressed.5 Although current management often prescribes corticosteroids as an induction therapy, recurrent use is being limited due to multiple side effects and a loss of efficacy.6 To maintain remission, early introduction of Aza or 6-mercaptopurine has become the standard of care in most centres.7 It is generally prescribed after confirmation of normal thiopurine methyl transferase levels and genotype,8 as they reflect the risk of severe side effects of these medications. Over the last 10 years, biologicals, monoclonal antibodies blocking specific cytokines or cytokine–receptor interactions, were introduced with great success in adults and children for IBD treatment. For the induction and maintenance of mild to moderate Crohn's disease, its efficacy appeared to be better in children than in adults.9 …
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