Treatment of antibiotic-associated Clostridium difficile diarrhea with oral vancomycin

The impact of Clostridium difficile on paediatric surgical practice: a systematic review

PURPOSE

The pathogenic potential of Clostridium difficile in children remains a controversial subject as healthy infants can be colonised by this organism. However recent analyses have clarified that C. difficile is an important enteropath in paediatric populations, particularly in antibiotic-associated diarrhoea. Paediatric surgical patients including those with Hirschsprung's disease (HD) may be especially vulnerable to C. difficile infection (CDI) and complicated C. difficile enterocolitis such as pseudomembranous colitis may require surgical management if refractory to medical therapy. Reports of increasing prevalence and emergence of hyper-virulent strains of C. difficile worldwide prompted an examination of the literature to assess the impact of CDI on current paediatric surgical practise.

METHODS

The literature was searched using a combination of the MESH terms "hirschsprung's disease", "enterocolitis", "clostridium difficile", and "children". Cases of Hirschsprung's associated enterocolitis (HAEC) investigated for C. difficile and complicated CDI in non HD patients were identified and analysed for clinical parameters, diagnostic evaluations, surgical interventions and outcome.

RESULTS

Pathogen isolation in HAEC was infrequently described. Only 98 children have been reported with C. difficile during an episode of HAEC over the last 40 years and aetiology remains unclear as asymptomatic carriage of C. difficile in HD occurs. Nonetheless 34 confirmed cases of pseudomembranous colitis complicating HD are reported in the literature with an associated 50 % mortality rate. Over 20 % of non Hirschsprung's patients with reported severe or complicated CDI required operative intervention. The need for surgery was associated with the presence of co-morbidity and high mortality occurred in this group.

CONCLUSION

Severe or complicated CDI in both HD and non HD paediatric patients is associated with high mortality and often requires surgical intervention. Although these patient cohorts represent a small number of cases, CDI should be suspected in children presenting with enterocolitis to enable early diagnosis and timely surgical intervention, particularly in patients with co-morbid conditions or preceding antibiotic use.

Bacterial enteric infections in children: etiology, clinical manifestations and antimicrobial therapy

Bacterial enteric infections have a huge impact on human health, particularly among the pediatric population. Despite the explosion of knowledge of the pathogenesis of bacterial enteric infections experienced in the past decade, the number of diarrheal episodes and childhood deaths reported continues to increase in many areas of the world. Specific antimicrobial therapy is indicated for certain confirmed infections, notably shigellosis, enterotoxigenic and enteroinvasive Escherichia coli infections, typhoid fever and cholera. Antimicrobial therapy may have a role in severe and prolonged gastrointestinal illness caused by nontyphoid Salmonella and Campylobacter. However, the use of antimicrobial agents may increase the risk of hemolytic uremic syndrome in children with E. coli O157:H7 infection. Bacterial genome sequencing and better understanding of the pathogenic mechanisms involved in the onset of diarrhea are leading to new preventive interventions, such as enteric vaccines, which may have a significant impact on the magnitude of this human plague.

Mammalian epithelial cell line kit for detection of Clostridium difficile toxin

The performance characteristics of a mammalian epithelial (MEP) cell line kit (Cytotoxi Test; Advanced Clinical Diagnostics, Toledo, Ohio) for the detection of Clostridium difficile toxin was compared with that of conventional tissue culture assays with human embryonic lung (HEL) cells in shell vials and human foreskin fibroblasts (HFFs) in test tubes. One hundred forty-nine stool samples were tested. The MEP cells were at least as sensitive as the HEL cells for use in C. difficile toxin detection. Results for the MEP cells were also obtained considerably more rapidly than those for HEL cells when the cells were examined at 4 and 24 h and then every 24 h for up to 5 days. Approximately one-third of all positive MEP cells were detected at 4 h and 95% were detected by 48 h. In comparison, in the HEL shell vial monolayers, only 6% of the positive cells were detectable at 4 h and 76% were detectable at 48 h. The times for C. difficile toxin-induced cytotoxicity in HFF cells were similar to those in HEL cells. Shell vials carrying HEL cell monolayers (ViroMed Laboratories Inc., Minnetonka, Minn.) are a sensitive and reliable commercial source for the detection of C. difficile toxin, although they cannot detect C. difficile as rapidly as the Cytotoxi test with the MEP cell monolayers.

Oral vancomycin-induced rash: case report and review of the literature

Disseminated rash and pruritus are described in an 82-year-old woman with chronic renal failure following administration of oral vancomycin hydrochloride 125 mg q6h for the treatment of Clostridium difficile colitis. Renal function was estimated to be 0.27 mL/s based on a serum creatinine of 177 mumol/L. After eight days of therapy, she developed a slightly raised maculopapular rash on her legs and torso, which spread to her abdomen and arms with continued treatment. Vancomycin was discontinued and the patient was treated symptomatically. The rash cleared and did not recur. Rechallenge with vancomycin was not initiated. No other changes in medications or initiations of new medications occurred during the time of treatment with vancomycin. The patient denied any previous immunologically mediated reactions to medications. Maculopapular rash is rare secondary to vancomycin administration, particularly after oral administration. Although clinically significant serum concentrations can be obtained in patients treated with oral vancomycin who have concomitant C. difficile colitis and renal failure, there has not been a clear correlation between these concentrations and any reported adverse sequelae. This case supports the possible occurrence of a true allergic reaction secondary to low-dose oral vancomycin administration.

Therapy for acute infectious diarrhea in children

This article reviews current recommendations of therapy with antidiarrheal compounds and antimicrobial agents for acute infectious diarrhea in children. In most infants and children with acute infectious diarrhea, treatment with antidiarrheal compounds is not indicated. Many of these compounds interfere with identification of enteropathogens in stool specimens, and the antimotility class has an overdose potential. Antimicrobial therapy is given to reduce symptoms and to prevent the spread of infection by decreasing fecal shedding of organisms. Although effective therapy is not available for patients with enteric viruses, Cryptosporidium, and Microsporidium, therapy is useful for children with amebiasis, antimicrobial-associated colitis, cholera, giardiasis, various forms of Escherichia coli diarrhea and Salmonella disease, isosporiasis, shigellosis, and strongyloidiasis. For several other conditions, antimicrobial therapy is of questionable benefit (infection with Campylobacter jejuni or Yersinia enterocolitica, intestinal salmonellosis and enterohemorrhagic E. coli infection). Compounds such as the fluoroquinolones, which are effective in the treatment of acute infectious diarrhea in adults, are not approved for use in children because of potential side effects. Many bacterial, viral, and parasitic organisms cause acute infectious diarrhea; appropriate antimicrobial therapy requires the accurate, rapid identification of the offending enteropathogen. In children with an underlying illness such as acquired immunodeficiency syndrome, manifestations may be prolonged, severe, and recurrent despite appropriate therapy.

Bacterial gastroenteritis

Acute diarrhea is a major cause of childhood morbidity. Important advances in the understanding of bacterial gastroenteritis have been made in the past two decades. This article reviews the epidemiology, pathogenesis, and methods of diagnosis of bacterial gastroenteritis. Bacterial enteric pathogens common to North America are discussed in more detail.

Trimethoprim/sulfamethoxazole-associated pseudomembranous colitis

A case of TMP/SMX-associated pseudomembranous colitis is described in a patient being treated for a urinary tract infection. Pseudomembranes are visualized on proctosigmoidoscopy, and stool cultures identified Clostridium difficile as the causative organism. The patient was treated successfully with oral vancomycin. A review of this infrequently reported adverse reaction to TMP/SMX is presented, emphasizing etiology and treatment.

Treatment of Clostridium difficile colitis and diarrhea with vancomycin

Toxigenic Clostridium difficle is the major cause of antibiotic-associated colitis and is susceptible to vancomycin at fecal concentrations achieved with oral therapy. The effect of oral vancomycin was studied in 16 patients with C. difficile-related diarrhea or colitis, 12 of whom had colitis documented by endoscopy, biopsy, and/or barium enema. Four patients had antibiotic-associated diarrhea and possibly antibiotic-associated colitis, because sigmoidoscopy either showed normal results (two patients) or was not performed (two patients). Nineteen episodes of diarrhea were treated with oral vancomycin in two dosage regimens for three to 14 days. Twelve patients received 2 g daily, and four patients initially received 1 g or less per day. Within 48 hours of the start of vancomycin therapy, 14 of 16 patients (87 percent) showed a decrease in temperature, abdominal pain and diarrhea. Diarrhea ceased completely within two days of the start of vancomycin in nine episodes, within three to seven days in six episodes, and within eight to 14 days in the remaining four episodes, and within eight to 14 days in the remaining four episodes. Diarrhea recurred in two of these patients (12 percent) when the drug inciting the initial episode of colitis was given again 42 days or more after vancomycin therapy was stopped; both patients responded again to retreatment with vancomycin. Oral vancomycin is an effective treatment of C. difficile-related colitis and diarrhea.