Evaluation of the addition of intravenous metronidazole to oral vancomycin therapy in critically ill patients with non-fulminant, severe Clostridioides difficile infection.
Pharmacotherapy. 2020 Apr 04;:
Authors: Vega AD, Heil EL, Blackman AL, Banoub M, Kristie Johnson J, Leekha S, Claeys KC
BACKGROUND: Data on the impact of combination therapy (intravenous metronidazole [IV MTZ] plus oral vancomycin [PO VAN]) on clinical outcomes in intensive care untie (ICU ) patients with severe, non-fulminant CDI, including NAP1-positive samples, is lacking.
METHODS: Retrospective, observational cohort of adult patients that developed CDI in the ICU diagnosed with severe, non-fulminant CDI who received PO VAN. Patients with an order for IV MTZ started within 72 hours of PO VAN and who received at least 72 hours of combined therapy composed the combination therapy group. A subset of patients had stool samples collected for NAP1 testing. An additional subset was matched by Acute Physiology and Chronic Health Evaluation (APACHE) II scores. The primary outcome was inpatient all-cause mortality within 30-days of CDI diagnosis.
RESULTS: A total of 138 patients were included; 60 (43.5%) patients in the combination group. Compared to the PO VAN group, those in the combination group had higher white blood cell counts at diagnosis (15.9 [interquartile range (IQR) 10.2, 21.1] versus 20.9 [IQR 16.2, 29] cells/mm3 , P < 0.001), respectively. Overall inpatient mortality was higher in the combination group, but 30-day mortality was not significantly different between groups (12.8% monotherapy versus 18.3% combination, P = 0.371). This finding was the same for the APACHE II-matched subgroup (n = 96), 14.6% monotherapy versus 18.8% combination, P = 0.785. NAP1 testing was completed in 42 patients; 11 were positive (26.2%). Patients who were NAP1 positive were more likely to receive IV MTZ (54.5% versus 19.4%, P = 0.026).
CONCLUSION: Compared to PO VAN, combination therapy with IV MTZ was not associated with better clinical outcomes in severe, non-fulminant CDI in ICU patients.
PMID: 32246501 [PubMed - as supplied by publisher]