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. 2015 Jun;7(6):422-7.
doi: 10.14740/jocmr2117w. Epub 2015 Apr 8.

Vancomycin Enemas as Adjunctive Therapy for Clostridium difficile Infection

Mark Malamood  1 , Eric Nellis  1 , Adam C Ehrlich  1 , Frank K Friedenberg  1
Affiliations

Vancomycin Enemas as Adjunctive Therapy for Clostridium difficile Infection

Mark Malamood et al. J Clin Med Res. 2015 Jun.

Abstract

Background: For severe, complicated Clostridium difficile infection (CDI), concomitant treatment with IV metronidazole and oral vancomycin is usually prescribed. Sometimes vancomycin per rectum (VPR) is added to increase colonic drug delivery. Our purpose was to examine clinical outcomes of patients with CDI treated with VPR and compare results to a matched control group.

Methods: This was a retrospective case-control study in a setting of tertiary-care ICU on diarrhea patients with a positive toxin test for C. difficile. We identified all ICU patients prescribed VPR from January 2003 to December 2013. The dose of VPR mixed in 100 cc of tap water ranged from 125 to 250 mg Q 6 - 8 hours. All patients had diarrhea and a positive test for C. difficile toxin. Included patients received ≥ 4 doses of VPR. The primary outcome was the combined endpoint of colon surgery or death. We matched VPR cases 1:2 with CDI controls that had identical APACHE II scores.

Results: We identified 24 CDI patients who received VPR and met inclusion criteria: 11 male, mean age 61.8 ± 15.9 years. All patients received concomitant CDI therapy. Four patients (16.7%) required colectomy, and overall mortality was 45.8%. For the 48 controls, need for surgery was identical (16.7%; P = 1.00). The mortality rate also did not differ (41.7%; P = 0.74). For the combined outcome of surgery or death, the rate was 45.8% for the controls and 50.0% for the VPR group (P = 0.73).

Conclusion: In a case-control study, the use of VPR was not demonstrated to reduce the need for colectomy or decrease mortality. Based on our modest sample size and failure to show efficacy, we cannot strongly advocate for the use of VPR.

Keywords: C. difficile infection; Colectomy; Enema; Vancomycin.

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Figures

Figure 1
Figure 1
CDI treatment for the control group (top) and VPR group (bottom). To be listed as exposed to antimicrobial, the patient had to receive at least 1 day of that therapy. Number of antibiotics > number of patients due to concomitant therapy.
Figure 2
Figure 2
Flow chart for combined primary outcomes.
Figure 3
Figure 3
Plot of odds ratio and 95% confidence interval of variables independently associated with the combined endpoint of colectomy and death.
See this image and copyright information in PMC

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