Continuous Enteral Vancomycin Infusion in ICU Patients With CDI Shows Promise

Continuous enteral vancomycin therapy may be an effective treatment approach for patients with severe Clostridioides difficile infection (CDI), specifically those with a high surgical risk, according to a study published in Cureus.

CDI is the leading cause of diarrhea in hospitalized patients and a significant health care-associated infection that is associated with a considerable economic burden worldwide. Annually in the United States, approximately 453,000 cases of CDI are diagnosed with 29,000 associated deaths, which translates to an economic burden of up to $3 billion dollars, according to the study.

Corresponding study author Omar Rahman, MD, of the Indiana University School of Medicine, and colleagues, noted that although the mildest cases of CDI may present only with diarrhea, severe cases can involve fulminant colitis or small bowel enteritis, and recurrent CDI. The investigators noted that new treatment options for patients with CDI is a significant unmet need.

“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,” the authors wrote.

Current guidelines for patients with severe CDI-related colitis is oral vancomycin plus intravenous metronidazole. If that fails, the guidelines suggest early total colectomy. For patients with a high surgical risk, loop ileostomy creation and enteral vancomycin infusion are recommended; however, the authors noted that invasive procedures are frequently unsuccessful.

Because of this, the investigators sought to evaluate whether continuous enteral vancomycin may be more successful if the infusion was done via a post-pyloric feeding tube.

The study authors identified 11 adult patients hospitalized between 2012 and 2016 in the intensive care unit (ICU) for severe CDI and who were administered continuous enteral vancomycin after the failure of conventional therapy. Vancomycin was put into an enteral solution at a rate of 1-2 mg/ml, and then continuously administered via 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 following treatment.

The treatment was deemed a failure in 2 patients who required total colectomy. At 28 days, 5 patients had died, 3 of which were attributable to CDI, according to the study.

The investigators noted that 80% of the patients in their study were in shock at the time enteral vancomycin was initiated, whereas the remaining 20% were considered too frail for surgery. On average, they received enteral vancomycin for 168 hours.

They cautioned that the study has significant limitations, including the small sample size and its retrospective nature. Because it was retrospective, the investigators could not confirm that production of the cytotoxin had been eradicated for each patient and they were unable to quantify the risk associated with the therapy. They added that it will be important to have additional prospective studies before the efficacy of the treatment can be proven.

“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,” the authors wrote.

Reference

Peters H, Iqbal A, Miller E, et al. (March 05, 2022) Outcomes of Continuous Enteral Vancomycin Infusion in Intensive Care Unit Patients: A Novel Treatment Modality for Severe Clostridium Difficile Colitis. Cureus 14(3): e22872. doi:10.7759/cureus.22872. Accessed April 18, 2022.