Intracolonic Vancomycin for Severe Clostridium difficile Colitis

Abstract

Background: Clostridium difficile colitis is associated with increased age, antibiotic usage, and hospitalization. Severe C. difficile colitis refractory to medical therapy may require surgical intervention including subtotal colectomy. We initiated an adjuvant intracolonic vancomycin (ICV) enema protocol for inpatients with severe C. difficile colitis and compared the response to this therapy in patients from the community and nursing homes. Methods: A single-hospital, retrospective chart review was done on 47 consecutive patients with C. difficile colitis treated with ICV (1 g/500 mL normal saline q6h) from January 2007 through October 2009. The proportions of patients with the outcomes of response to the ICV protocol, need for subtotal colectomy, and death were described. Associations of patient characteristics with these outcomes were examined with bivariate tests and multivariable logistic models with adjustment for age, hypoalbuminemia, acidosis, and nursing-home status. Results: Thirty-three of 47 patients (70%) with severe C. difficile colitis responded to adjunct ICV with complete resolution without surgery. Incomplete responders who had surgery were more likely to survive than those patients who did not undergo subtotal colectomy (p < 0.01). Seven of nine patients who underwent surgery survived > 90 d, and overall, 37 of 47 patients (79%) survived after ICV therapy. Nursing-home residence, acidosis, and hypoalbuminemia were significantly associated with the non-resolution of colitis in bivariate analyses (all p < 0.01), whereas nursing-home residence and hypoalbuminemia showed non-significant trends toward association with death (p = 0.07 and p = 0.06, respectively). Multivariate logistic-regression models showed significant associations of acidosis with an incomplete response to ICV (p = 0.02), of older age with death (p = 0.04), and of hypoalbuminemia with both an incomplete response to ICV and death (both p = 0.04). No complications were attributable to ICV. Conclusion: Complete resolution without surgery was achieved in 70% in this series of patients with severe C. difficile colitis who received adjunct ICV therapy. A clinical trial will be needed to determine whether ICV as compared with standard therapy alone can reduce the need for surgery with non-inferior or superior outcomes.

Oral teicoplanin for successful treatment of severe refractory Clostridium difficile infection

“…Kim et al showed that the majority of patients who were given intracolonic vancomycin had complete resolution of symptoms although subsequently, two developed severe recurrence with fatal outcome [6]. Among our patients, four were given intracolonic vancomycin in addition to standard therapy before initiation of teicoplanin, but this did not result in clinical cure.…”

“…Another therapeutic option for severe refractory CDI is intracolonic delivery of vancomycin by rectal enema [6]. Kim et al showed that the majority of patients who were given intracolonic vancomycin had complete resolution of symptoms although subsequently, two developed severe recurrence with fatal outcome [6].…”

“…Despite existing guidelines, there is no defined protocol for treating severe refractory CDI, and literature data comes from individual case reports with different treatment approaches. Intravenous tygecyclin, intravenous immunoglobulins, oral vancomycin in higher doses, and vancomycin enema are some of the suggested treatment regimens but they were all applied to a small number of patients [3][4][5][6]. Oral teicoplanin is another antibiotic, which was proven to be successful in the treatment of patients with CDI, including those with severe disease [7,8].…”

Clostridium difficile Infection: Update on Diagnosis, Epidemiology, and Treatment Strategies

“…A single-center case series report of 47 patients with severe C. difficile colitis with surgical consultation recommended initiation of an adjuvant intracolonic vancomycin enema (1 g/500 mL normal saline every 6 h) protocol and 70% of patients responded with complete resolution without need for surgery. Multivariable logistic regression confirmed that acidosis and hypoalbuminemia were significantly associated with incomplete response to intracolonic vancomycin enema treatment [79].…”

The potential for emerging therapeutic options forClostridium difficileinfection

“…27 In cases of extremely severe C. difficile colitis, intracolonic vancomycin administration may have the potential to be used as an adjunct, to ensure higher concentrations of the drug in the colon. 32,33 This may involve the use of an intracolonic bolus with an intravenous solution of vancomycin. A rectal retention enema such as 500 mg of vancomycin in 1 L of saline solution may be another option.…”