Antibiotics for Treatment of Clostridium difficile Infection in Hospitalized Patients with Inflammatory Bowel Disease

Abstract

Patients with inflammatory bowel disease (IBD), namely ulcerative colitis (UC) and Crohn's disease (CD), have worse outcomes with Clostridium difficile infection (CDI), including increased readmissions, colectomy, and death. Oral vancomycin is recommended for the treatment of severe CDI, while metronidazole is the standard of care for nonsevere infection. We aimed to assess treatment outcomes of CDI in IBD. We conducted a retrospective observational study of inpatients with CDI and IBD from January 2006 through December 2010. CDI severity was assessed using published criteria. Outcomes included readmission for CDI within 30 days and 12 weeks, length of stay, colectomy, and death. A total of 114 patients met inclusion criteria (UC, 62; CD, 52). Thirty-day readmissions were more common among UC than CD patients (24.2% versus 9.6%; P ‫؍‬ 0.04). Same-admission colectomy occurred in 27.4% of UC patients and 0% of CD patients (P < 0.01). Severe CDI was more common among UC than CD patients (32.2% versus 19.4%; P ‫؍‬ 0.12) but not statistically significant. Two patients died from CDI-associated complications C lostridium difficile causes roughly 20% of antibiotic-associated diarrhea and is responsible for significant morbidity. Its incidence has more than doubled over the past decade (1). Historically, C. difficile infection (CDI) has been associated with such risk factors as antibiotic use, immune suppression and dysfunction, prolonged hospital stays, and advanced age (1-3).Inflammatory bowel disease (IBD) is generally classified as Crohn's disease (CD) or ulcerative colitis (UC), which manifest with intestinal symptoms, including diarrhea and abdominal pain. Patients with IBD are particularly susceptible to the effects of enterocolitic infections, due to underlying alterations in intestinal immunity coupled with often chronic exposure to immunosuppressive therapies. Recent studies have shown that patients with IBD have an increased incidence of developing CDI, with a 2-to 3-fold increase in patients with Crohn's disease and a 4-to 7-fold increase in patients with UC (4-7). Furthermore, patients with underlying IBD who develop CDI experience longer hospital stays and higher rates of colectomy and death than subjects without IBD (5, 8, 9). Consequently, CDI is estimated to have quadrupled the cost of hospitalizations to greater than $1 billion per year relative to matched hospitalizations (1, 10). Several agents have been evaluated for the treatment of CDI, including metronidazole and vancomycin (11).A randomized, controlled trial by Zar et al. demonstrated that vancomycin for the treatment of CDI was associated with improved outcomes in patients meeting criteria for severe CDI, but it conferred no significant advantage over metronidazole for nonsevere disease (12). Notably, patients with IBD were excluded from this trial, and there are no prospective trials comparing antibiotic regimens among patients with CDI and underlying IBD. Largely on the basis of the study by Zar and colleagues, current treatment guidelines rec...

Review article: the practical management of acute severe ulcerative colitis

“…CDI can be classified into severe and nonsevere based on the presence of endoscopic evidence of pseudomembranous colitis, treatment in the ICU or two or more of the following: age >60 years, temperature >38.3 °C, hypoalbuminaemia, or white cell count >15 000 cells/mm 3 . When compared to metronidazole, vancomycin use in nonsevere CDI was associated with lower 30‐day readmission (0% compared to 31%; P = 0.04) and results were suggestive of lower rates of 12‐week readmission (15% compared to 31%; P = 0.45) and colectomy during the index admission (15% compared to 24%; P = 0.70), although the latter two associations did not reach statistical significance . Although faecal microbiota transplantation appears to have a role in recurrent CDI, it has not been fully evaluated in patients with ASUC .…”

“…132 When compared to metronidazole, vancomycin use in nonsevere CDI was associated with lower 30-day readmission (0% compared to 31%; P = 0.04) and results were suggestive of lower rates of 12-week readmission (15% compared to 31%; P = 0.45) and colectomy during the index admission (15% compared to 24%; P = 0.70), although the latter two associations did not reach statistical significance. 133 Although faecal microbiota transplantation appears to have a role in recurrent CDI, it has not been fully evaluated in patients with ASUC. 134 A concern is the increased risk of bacterial translocation, given the ulcerated and denuded mucosa, which may increase the risk of systemic toxicity.…”

Aktualisierte S3-Leitlinie Colitis ulcerosa der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS)

“…Auch Patienten mit schwerer Infektion hatten weniger stationäre Wiederaufnahmen (0 % versus 70 %), aber tendenziell längere Krankenhausaufenthalte (19 versus 11 Tage) nach Vancomycintherapie (n = 9) verglichen mit einer Metronidazoltherapie (n = 10). Diese Studie ist die erste Untersuchung, die dafür spricht, Vancomycin bei Patienten mit CU primär einzusetzen [514].…”

Diagnóstico y manejo de colitis ulcerosa grave: Una mirada actualizada

“…En pacientes con EII, estudios han mostrado que el tratamiento con metronidazol oral de la ICD se asocia a mayores tasas de falla de tratamiento y recurrencia, comparado con vancomicina oral 19 . Por lo tanto, se recomienda el uso de esta última como terapia de primera línea en crisis grave de CU asociada a ICD.…”