Care of the Patient with IBD Requiring Hospitalization During the COVID-19 Pandemic



# Introduction
The COVID-19 pandemic has led to restriction of hospitalizations and unprecedented redeployment of healthcare resources. The management of IBD has been highly impacted. [bib_ref] Implications of COVID-19 for patients with pre-existing digestive diseases, Mao [/bib_ref] [bib_ref] Outcomes of COVID-19 in 79 patients with IBD in Italy: an IG-IBD..., Bezzio [/bib_ref] [bib_ref] Novel Coronavirus Disease (COVID-19) in patients with Inflammatory Bowel Diseases, Taxonera [/bib_ref] [bib_ref] AGA Clinical Practice Update on Management of Inflammatory Bowel Disease During the..., Rubin [/bib_ref] On the one hand, hospital admissions of IBD patients should be limited to reduce the risks of coronavirus transmission between hospitalized patients and to ensure that there is inpatient capacity to look after the many admissions with COVID-19. [bib_ref] Management of IBD during the COVID-19 outbreak: resetting clinical priorities, Danese [/bib_ref] On the other hand, delaying hospitalization of IBD patients with severe or complicated disease may increase the risk of poor outcomes. Surgery is also seriously impacted in the present context. [bib_ref] Medically Necessary, Time-Sensitive Procedures: Scoring System to Ethically and Efficiently Manage Resource..., Prachand [/bib_ref] [bib_ref] Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period..., Lei [/bib_ref] A number of emergencies require surgery in the short term, and delaying surgery in some cases may increase the risk of disease progression, post-operative morbidity and disease complications. Performance of endoscopic procedures is also impacted, with significant delays to routine endoscopy. [bib_ref] Endoscopy in inflammatory bowel diseases during the COVID-19 pandemic and post-pandemic period, Iacucci [/bib_ref] IBD patients do not appear to have an increased risk of being infected with SARS-CoV-2. [bib_ref] Outcomes of COVID-19 in 79 patients with IBD in Italy: an IG-IBD..., Bezzio [/bib_ref] [bib_ref] Covid-19 in Immune-Mediated Inflammatory Diseases -Case Series from New York, Haberman [/bib_ref] However, IBD patients who are infected with SARS-CoV-2 may have a higher risk of poor outcomes than the general population.This increased risk may be driven by concomitant medications, especially corticosteroids, but may also be associated with gastrointestinal inflammation, IBD itself or associated comorbidities. Additional risk factors for poor outcomes A c c e p t e d M a n u s c r i p t Manuscript Doi: 10.1093/ecco-jcc/jjaa150 from COVID-19 include older age, pre-existing cardiovascular and respiratory disease, obesity, diabetes and cigarette smoking. [bib_ref] Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients..., Wu [/bib_ref] While the use of immunosuppressing medications such as thiopurines, and biologics has been associated with increased risks of a range of infections in IBD patients, at this point, there is no evidence that IBD patients with COVID have worse outcomes if they receive these drugs. [bib_ref] Coronaviruses and Immunosuppressed Patients: The Facts During the Third Epidemic, D&apos;antiga [/bib_ref] [bib_ref] Are Patients with Inflammatory Bowel Disease at Increased Risk for Covid-19 Infection?, Monteleone [/bib_ref] National and international societies, including IOIBD, have recommended the maintenance of these therapies in the present context. 14 Which IBD drugs should be preferentially used to induce response or remission in patients with active IBD during the COVID-19 pandemic is unclear. There is even less evidence on how IBD patients with active disease should be treated according to their COVID-19 infectious status.
Manifestations and outcomes from COVID-19 infection are related to host defense responses. The hyper-inflammatory response may lead to organ failures, associated with a cytokine "storm", characterized by high levels of pro-inflammatory cytokines, such as TNF, several interleukins and chemokines. Immunomodulation of this hyperinflammatory state is currently being explored 15 , and there are several clinical trials in COVID-19 patients of immunomodulators or targeted therapies. [bib_ref] The cytokine release syndrome (CRS) of severe COVID-19 and Interleukin-6 receptor (IL-6R)..., Zhang [/bib_ref] It is possible that even if immunomodulators suppress viral immunity, they may exert a beneficial effect by controlling the hyperinflammatory state.
COVID-19 can cause diarrhea and abdominal pain and may mimic an IBD flare. [bib_ref] Covid-19 and the digestive system, Wong [/bib_ref] The virus can infect the gut, as demonstrated by a positive SARS-CoV-2 viral nucleocapsid positive staining in digestive biopsies. [bib_ref] Evidence for Gastrointestinal Infection of SARS-CoV-2, Xiao [/bib_ref] It is currently unknown if SARS-CoV-2 can cause relapse of or de novo IBD.
A striking characteristic of severe COVID-19 infections is the predisposition to develop thromboembolic complications. [bib_ref] Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019..., Tang [/bib_ref] [bib_ref] Prominent changes in blood coagulation of patients with SARS-CoV-2 infection, Han [/bib_ref] [bib_ref] Thromboprophylaxis and laboratory monitoring for in-hospital patients with COVID-19 -a Swiss consensus..., Casini [/bib_ref] [bib_ref] Acute Pulmonary Embolism Associated with COVID-19 Pneumonia Detected by Pulmonary CT Angiography, Grillet [/bib_ref] [bib_ref] Acute Pulmonary Embolism in COVID-19 Patients on CT Angiography and Relationship to..., Leonard-Lorant [/bib_ref] Given that IBD patients are already at risk, anticoagulation prophylaxis should be adapted to each situation. e. Depending on institutional policy and availability, testing for SARS-CoV-2 may be required prior to needed inpatient endoscopic, radiologic or surgical procedures, as even asymptomatic patients with SARS-CoV-2 infection may be at risk for postoperative ICU care and mortality [bib_ref] Minimally Invasive Surgery and the Novel Coronavirus Outbreak: Lessons Learned in China..., Zheng [/bib_ref] , and are at risk for infecting others. f. Ideally, and when possible, testing for SARS-CoV-2 should be performed before admission. We recommend to hospitalize the patient in a single room until the result of testing for SARS-CoV-2 is available.

## Evaluation for covid-19
a. Patients suspected of having COVID-19 should be tested for SARS-CoV-19 in the nasopharynx. Serologic antibody testing may also be used, provided that this testing is both accurate and has clinical relevance. Testing for SARS-CoV-2 is evolving and it is currently unclear which test will be best.
b. If testing for SARS-CoV-2 is negative, or if the patient is considered as immune, the patient can be admitted to a COVID-free unit. b. Radiologic procedures should be limited to those that are urgently needed or will directly influence management, e.g., AXR, CT or MR to evaluate for abscess or obstruction. In the current environment, CT may be preferred over MR due to faster acquisition time and easier deep cleaning of equipment.
c. Endoscopic procedures should be limited to those that are urgently needed or will directly influence management. Serum and stool biomarkers may have a more prominent role to play in this setting. (Refer to IOIBD Endoscopy guidance document.)

## Considerations for treatment of ibd in a patient with sars-cov-2
a. c. In cases of moderate-severe COVID-19, discontinuation of IBD therapies must be discussed case-by-case, according to IBD activity and treatment. Interestingly, some treatments such as steroids and even some biologics are considered and even assessed in ongoing clinical trials in the second phase of COVID-19 (so called cytokine storm). ii. For small perianal abscesses, it is reasonable to try a short course of antibiotic therapy before surgery. However, the role of oral antibiotic therapy alone versus surgical drainage for small abscesses in these patients is unknown.
iii. The presence of a large or complex perianal abscess in the CD patient requires surgery and should not be delayed. A c c e p t e d M a n u s c r i p t