Continuous Enteral Vancomycin Helpful in Cases of Severe Recurrent CDI

Continuous enteral vancomycin can be an effective treatment patients with severe Clostridioides difficile infection (CDI), according to a new report.

The study found the therapy worked in most patients who were at high surgical risk. The report was published in the journal Cureus.

Corresponding author Omar Rahman, MD, of the Indiana University School of Medicine, and colleagues, explained that while the mildest cases of CDI may present only with diarrhea, the more severe cases can involve fulminant colitis or small bowel enteritis, as well as recurrent CDI.

The investigators said there is an unmet need for new treatment options for these patients.

“Although antibiotics including metronidazole, fidaxomicin, and vancomycin have been described to be quite effective for this condition, recent studies that isolated the C difficile suggest reduced susceptibility and increased resistance to these antibiotics, which raises a serious concern in terms of continuing the usage of these antibiotics for the treatment of CDI,” they wrote.

The current guidelines for patients with severe CDI-related colitis is oral vancomycin plus intravenous metronidazole. If that fails, guidelines suggest early total colectomy. For patients at high surgical risk, however, loop ileostomy creation and enteral vancomycin infusion is recommended. Yet, the authors said that invasive procedures are often unsuccessful.

Instead, Rahman and colleagues wanted to know whether continuous enteral vancomycin might be more successful if the infusion was done via a post-pyloric feeding tube.

The investigators identified a cohort of 11 adult patients who were hospitalized between 2012 and 2016 in the intensive care unit (ICU) for severe CDI and were given continuous enteral vancomycin after conventional therapy failed. Vancomycin was put into an enteral solution at a rate of 1-2 mg/ml, and then continuously sent through a post-pyloric feeding tube at a rate of 42 ml/hour.

Two-thirds of the patients (7 people) were female, and the median age was 64 years. The data showed that 7 patients experienced clinical improvement after the treatment. Two patients required total colectomy and thus the treatment was considered a failure in those two patients. At 28 days, 5 of the patients had died, but only 3 cases were attributable to CDI, the investigators said.

Rahman and colleagues noted that 80% of the patients in their study were in shock at the time enteral vancomycin was started, and the remaining 20% were considered too frail for surgery. On average, they received enteral vancomycin for 168 hours, they said.

“Based on our observations, high clinical response rate, and favorable outcomes, [continuous enteral vancomycin] can be used as a treatment option in patients with severe CDI who are not responsive to conventional oral vancomycin treatment,” they wrote.

However, the investigators also cautioned that their report was subject to significant limitations, including the small sample size and the study’s retrospective nature. Because it was retrospective, the authors said they were not able to confirm that production of the cytotoxin had been eradicated for each patient; they also were unable to quantify the risk associated with the therapy. They said it will be important to have additional, prospective studies, before the efficacy of the treatment can be proven.