Treatment of First Recurrences of Clostridium difficile-Associated Disease: Waiting for New Treatment Options

• Published in: Clinical infectious diseases 2006-03, Vol.42 (6), p.765-767
• Main Author: Louie, Thomas J.
• Format: Article
• Language: English
• Subjects: Anti-Bacterial Agents - therapeutic use; Bacteria; Clinical trials; Clostridium difficile - pathogenicity; Disease Outbreaks; Drug therapy; Enterocolitis, Pseudomembranous - drug therapy; Enterocolitis, Pseudomembranous - epidemiology; Humans; Mortality; Quebec - epidemiology; Recurrence; Risk Factors; Treatment Outcome
• ISSN: 1058-4838; 1537-6591
• DOI: 10.1086/501137

A major question arising in the infectious diseases community is whether and when to abandon the use of metronidazole as first-line therapy for C. difficile diarrhea, both for initial and recurrent episodes in the face of the changing epidemiology of this reemerging infectious disease [2, 3]. In the presence of an outbreak of CDAD in which spores of the outbreak strain become dominant in the hospital, the traditional definitions of endogenous relapse of infection with the same strain or exogenous reinfection with a different strain (or strains) become much less incisive, because this disease perpetuates itself via intestinal and environmental persistence of spores. (According to table 2 in the article by Pepin and colleagues, combined therapy with both vancomycin and metronidazole appeared to result in a higher likelihood of a complicated course; this was also shown in the initial infection study [8], and the complicated course was much more likely associated with the initiation of combination therapy for patients who were severely ill, rather than the development of severe disease as a result of combined therapy.) It was concluded that there was a tendency for vancomycin to be less likely to be accompanied by a complicated course, but the trend did not reach statistical significance. However, several caveats apply: the observations are not based on randomized, controlled studies; it is a single health care center's experience; the health care center had experienced an outbreak of infection with ribotype 027/NAP-l strain; and the definition of a complicated course including all-cause mortality within 30 days.