Comparison of Clinical and Microbiological Response to Treatment of<i>Clostridium difficile</i>–Associated Disease with Metronidazole and Vancomycin

Al‐Nassir, Wafa N.; Sethi, Ajay K.; Nerandzic, Michelle M.; Bobulsky, Greg S.; Jump, Robin L.P.; Donskey, Curtis J.

doi:10.1086/588293

Cited by 151 publications

(100 citation statements)

References 26 publications

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“…Accurate stratifi cation of patients based upon severity of disease using these criteria will ensure adequate and timely institution of appropriate therapy without over-treating too many patients. ( 50,51 ). In one, 150 patients were stratifi ed by an ad-hoc defi nition of CDI severity and then randomized to oral metronidazole or vancomycin ( 50 ).…”

Section: Management Of Mild Moderate and Severe CDImentioning

confidence: 99%

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Surawicz

Brandt

Binion

et al. 2013

American Journal of Gastroenterology

1,478

1,408

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Clostridium diffi cile infection (CDI) is a leading cause of hospital-associated gastrointestinal illness and places a high burden on our health-care system. Patients with CDI typically have extended lengths-of-stay in hospitals, and CDI is a frequent cause of large hospital outbreaks of disease. This guideline provides recommendations for the diagnosis and management of patients with CDI as well as for the prevention and control of outbreaks while supplementing previously published guidelines. New molecular diagnostic stool tests will likely replace current enzyme immunoassay tests. We suggest treatment of patients be stratifi ed depending on whether they have mild-to-moderate, severe, or complicated disease. Therapy with metronidazole remains the choice for mildto-moderate disease but may not be adequate for patients with severe or complicated disease. We propose a classifi cation of disease severity to guide therapy that is useful for clinicians. We review current treatment options for patients with recurrent CDI and recommendations for the control and prevention of outbreaks of CDI. Am J Gastroenterol 2013; 108:478-498; doi: 10.1038/ajg.2013 12. In patients in whom oral antibiotics cannot reach a segment of the colon, such as with Hartman's pouch, ileostomy, or colon diversion, vancomycin therapy delivered via enema should be added to treatments above until the patient improves. (Conditional recommendation, low-quality evidence)13. The use of anti-peristaltic agents to control diarrhea from confi rmed or suspected CDI should be limited or avoided, as they may obscure symptoms and precipitate complicated disease. Use of anti-peristaltic agents in the setting of CDI must always be accompanied by medical therapy for CDI. (Strong recommendation, low-quality evidence) Management of severe and complicated CDI14. Supportive care should be delivered to all patients and includes intravenous fl uid resuscitation, electrolyte replacement, and pharmacological venous thromboembolism prophylaxis. Furthermore, in the absence of ileus or signifi cant abdominal distention, oral or enteral feeding should be continued. 17. Vancomycin delivered orally (500 mg four times per day) and per rectum (500 mg in a volume of 500 ml four times a day) plus intravenous metronidazole (500 mg three times a day) is the treatment of choice for patients with complicated CDI with ileus or toxic colon and / or signifi cant abdominal distention. (Strong recommendation, low-quality evidence)18. Surgical consult should be obtained in all patients with complicated CDI. Surgical therapy should be considered in patients with any one of the following attributed to CDI: hypotension requiring vasopressor therapy; clinical signs of sepsis and organ dysfunction (renal and pulmonary); mental status changes; white blood cell count ≥ 50,000 cells / μ l, lactate ≥ 5 mmol / l; or failure to improve on medical therapy after 5 days. (Strong recommendation, moderate-quality evidence) Management of recurrent CDI (RCDI)19. The fi rst recurrence of CDI can be treated ...

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Section: Management Of Mild Moderate and Severe CDImentioning

confidence: 99%

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Surawicz

Brandt

Binion

et al. 2013

American Journal of Gastroenterology

1,478

1,408

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“…16,18 The relative risks of patient-related versus strainrelated factors for recurrence are unknown, as is the comparative efficacy of first-line agents in treating infections associated with the NAP1 strain of C. difficile. 21,22 The treatment of recurrent C. difficile infection is often based on empiric selection from relatively few options supported by limited clinical evidence. Accordingly, this paper reviews the recommendations of the Society for Hospital Epidemiology of America and the Infectious Diseases Society of America (SHEA-IDSA; guidelines published in May 2010) and the American College of Gastroenterology (ACOG; guidelines published in February 2013), as well as other references describing treatment strategies for first and second or later recurrence of C. difficile infection.…”

Section: R Ecurrentmentioning

confidence: 99%

“…25 However, more recent data, including results for patients with NAP1 infection, have indicated treatment failure rates up to 50% with metronidazole. 11,13,[21][22][23] In one prospective observational study of 52 patients with C. difficile infection, with 60% of cases associated with the NAP1 strain, those treated with vancomycin were more likely to have undetectable levels of C. difficile toxin (adjusted hazard ratio [HR] 3.99, 95% confidence interval [CI] 1.41-11.3; p = 0.09) and resolution of diarrhea (adjusted HR 4.17, 95% CI 1.53-11.4; p = 0.05) during the first 5 days of therapy than those who received metronidazole. 22 Furthermore, therapy was changed because of persistent symptoms in 29% (10/34) of patients treated with metronidazole but none of the 18 treated with vancomycin.…”

Section: Treatment Of First Recurrencementioning

confidence: 99%

Treatment Strategies for Recurrent Clostridium difficile Infection

Leong

Zelenitsky

2013

CJHP

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“…[1][2][3][4][5]9,30 Some preliminary data and much theoretical speculation, however, have led to assertions that oral vancomycin may provide a small advantage in patients with more severe diseases and may be better at decreasing the rate of relapse. [30][31][32][33][34] One recent report suggests that treatment 'failure' with metronidazole may reflect a slower and more variable activity of metronidazole as compared with vancomycin. 33 Although the preferred use of these agents is currently debated, it is clear that metronidazole has more side effects than vancomycin, a drug that also has the advantage of being poorly absorbed and exhibiting near ideal pharmacologic characteristics for treating CDAD.…”

Section: Management Of Cdadmentioning

confidence: 99%

“…[30][31][32][33][34] One recent report suggests that treatment 'failure' with metronidazole may reflect a slower and more variable activity of metronidazole as compared with vancomycin. 33 Although the preferred use of these agents is currently debated, it is clear that metronidazole has more side effects than vancomycin, a drug that also has the advantage of being poorly absorbed and exhibiting near ideal pharmacologic characteristics for treating CDAD. 34 There are few, if any, studies to support combination therapy for CDAD, although it is generally recommended that the seriously ill CDAD patient be treated with a combination of oral vancomycin and i.v.…”

Section: Management Of Cdadmentioning

confidence: 99%

Clostridium difficile-associated disease in human stem cell transplant recipients: coming epidemic or false alarm?

Bobak

Arfons

Creger

et al. 2008

Bone Marrow Transplant

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Clostridium difficile is the most common cause of nosocomial diarrhea in the United States and Europe, and is a cause of significant morbidity and mortality among hospitalized patients. A newly identified epidemic strain has been associated with many hospital outbreaks of C. difficile-associated disease (CDAD), raising the concern of an escalating burden of CDAD among at-risk patients. Hematopoietic SCT (HSCT) recipients are known to be at increased risk for a wide variety of infectious complications, including CDAD as a result of prolonged hospitalizations, exposure to broad-spectrum antibiotics, altered integrity of the intestinal mucosa and GVHD. The incidence of CDAD in the HSCT population has been reported as high as 20% in some large series. The frequency and seriousness of CDAD in this defined group as compared with the general hospital population, however, are not clearly delineated. We discuss the epidemiology and diagnosis of CDAD and review recent studies examining the risk factors and characteristics of CDAD in HSCT recipients. Finally, we provide a management algorithm for the diagnosis and treatment of CDAD at our institution.

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Comparison of Clinical and Microbiological Response to Treatment ofClostridium difficile–Associated Disease with Metronidazole and Vancomycin

Cited by 151 publications

References 26 publications

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Guidelines for Diagnosis, Treatment, and Prevention of Clostridium difficile Infections

Treatment Strategies for Recurrent Clostridium difficile Infection

Clostridium difficile-associated disease in human stem cell transplant recipients: coming epidemic or false alarm?

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