Intracolonic vancomycin for severe Clostridium difficile colitis

Peter K. Kim, Heesun C. Huh, Hillel W. Cohen, Elyssa J. Feinberg, Salman Ahmad, Christina M. Coyle, Sheldon Teperman, Hugh Boothe

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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.

Original languageEnglish (US)
Pages (from-to)532-539
Number of pages8
JournalSurgical Infections
Volume14
Issue number6
DOIs
StatePublished - Dec 1 2013

Fingerprint

Clostridium difficile
Colitis
Vancomycin
Hypoalbuminemia
Nursing Homes
Colectomy
Acidosis
Logistic Models
Therapeutics
Enema
Inpatients
Hospitalization
Clinical Trials
Anti-Bacterial Agents

ASJC Scopus subject areas

  • Surgery
  • Infectious Diseases
  • Microbiology (medical)

Cite this

Kim, P. K., Huh, H. C., Cohen, H. W., Feinberg, E. J., Ahmad, S., Coyle, C. M., ... Boothe, H. (2013). Intracolonic vancomycin for severe Clostridium difficile colitis. Surgical Infections, 14(6), 532-539. https://doi.org/10.1089/sur.2012.158

Intracolonic vancomycin for severe Clostridium difficile colitis. / Kim, Peter K.; Huh, Heesun C.; Cohen, Hillel W.; Feinberg, Elyssa J.; Ahmad, Salman; Coyle, Christina M.; Teperman, Sheldon; Boothe, Hugh.

In: Surgical Infections, Vol. 14, No. 6, 01.12.2013, p. 532-539.

Research output: Contribution to journalArticle

Kim, PK, Huh, HC, Cohen, HW, Feinberg, EJ, Ahmad, S, Coyle, CM, Teperman, S & Boothe, H 2013, 'Intracolonic vancomycin for severe Clostridium difficile colitis', Surgical Infections, vol. 14, no. 6, pp. 532-539. https://doi.org/10.1089/sur.2012.158
Kim, Peter K. ; Huh, Heesun C. ; Cohen, Hillel W. ; Feinberg, Elyssa J. ; Ahmad, Salman ; Coyle, Christina M. ; Teperman, Sheldon ; Boothe, Hugh. / Intracolonic vancomycin for severe Clostridium difficile colitis. In: Surgical Infections. 2013 ; Vol. 14, No. 6. pp. 532-539.
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N2 - 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.

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