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Background: Infliximab is a chimeric monoclonal anti TNFa whose effectiveness during IBD has been demonstrated especially in Crohn's disease and more recently in the course of ulcerative colitis. However, a significant number of patients estimated to be between 20 to 30% of patients with crohn's disease and 30 to 40% with ulcerative colitis, not responding to treatment with infliximab, thus the failure of infliximab is a real problem which the clinician should resolve quickly. This review aimed to describe predictif factors and mecanique of infliximab failure during MICI treatment and to precise differents therapeutique options., Methods: Literature review, Results: The definition of failure of infliximab during inflammatory bowel disease is not consensual; it is very varied from one study to another. However, we define two types of non response to infliximab as either primary or secondary. Factors predisposing to failure of infliximab have been reported. Some alternative therapies may be recommended. The sequential treatment comparing to the episodic treatment by infliximab is better in obtaining an endoscopic and clinical response of patients with inflammatory bowel disease. The injection of infliximab should be preceded by the taking of immunosuppressive and concomitant use of these during treatment significantly improves the clinical response of patients. Also, the increased time of exposure to infliximab, either by increasing doses or shorter intervals of infusion therapy is a considerable therapy alternative. Moreover, thanks to the advent of new molecular anti TNFa, a relay by adalinumab or certolizumab may be proposed., Conclusion: The failure of infliximab is a common situation but not so easily solved by the clinician. The alternative therapies are aimed at strengthening; improve the action of infliximab or to change the therapeutic molecule. The efficacy of infliximab, being dependent on the rate of infliximab antibody, a therapeutic strategy based on the serum concentration of infliximab is proposed. If the serum concentration is low or undetectable suggesting a high rate of antibody, a change of molecule should be promoted. As if against the serum concentration is high or intermediate, increased time of exposure to infliximab or the addition of immunosuppressive can be proposed.

Background: Infliximab has been an effective chimerical monoclonal antibody in Crohn's disease. Infliximab is available in Tunisia for a few years., Aims: To determine the results of the treatment of Crohn's disease by infliximab., Methods: We undertook a retrospective study relating to all the Crohn's disease patients and treated by infliximab. For all the patients, we specified the indication of the treatment, the result of the induction treatment, the recourse or not to a sequential treatment and the adverse effects of the treatment., Results: Our study related to 20 patients. It was in the majority of the cases an anoperineal and fistulizing form (15 case). Good response to the induction treatment was noted in 15 patients (75%). A sequential treatment by infliximab was undertaken among seven patients, with good results in the short and medium term. A case of death related to the treatment was noted in our series, as mortal milliary tuberculosis appeared under treatment., Conclusion: Infliximab must be reserved for particular situations of the Crohn's disease. The pre-therapeutic assessment must be complete and the monitoring of the patients must be strict, while insisting on the possibility of reactivation of latent tuberculosis in Tunisia.

Infliximab is a chimeric monoclonal antibody to tumor necrosis factor a. Induction therapy with infliximab is indicated for treatment of refractory Crohn's disease and for reduction in the number of draining fistulas in fistulizing Crohn's disease. Indications for maintenance therapy with infliximab include maintenance of remission in active Crohn's disease who responded to initial induction therapy with infliximab and maintenance of fistula improvement who responded to initial therapy with infliximab. Side effects of infliximab are infusion reactions, immunogenicity, induction of DNA antibodies and infection complications including tuberculosis.

We report the first Tunisian case of miliary tuberculosis in a patient who received Infliximab for Crohn's disease with uretrorectal and ano-perineal fistula developed 4 weeks after the start of treatment. We suggest that diagnosis of latent tuberculosis infection is important before treatment with Infliximab is initiated and that antituberculous medication must be prescribed immediately in case of occurrence of unexplained fever after treatment with Infliximab.