10. The Management Of Pseudomembranous Colitis
- 1. PSEUDOMEMBRANOUS COLITIS The Management Of Siti Nurbaya Mohd Nawi Med 4 May 29 2006 By
- 2. Introduction Pseudomembranous colitis is a disease commonly associated with hospitalisation or prior antibiotic exposure Results from an inflammatory reaction of the bowel wall to the luminal toxin produced by Clostridium difficile
- 3. Initial Management Discontinuation of antibiotics or other potentially inciting agents Supportive care for diarrhea i.e fluid repletion and electrolyte balance 25% of cases resolve without further treatment Isolation precautions i.e proper handwashing and disinfections
- 4. Specific Therapy Specific for Clostridium difficile First line therapy – Oral metronidazole, oral vancomycin Second line therapy – Oral bacitracin, Teicoplanin, Fusidic acid, Anion exchange resin agents Surgical intervention
- 5. Metronidazole Effective (response rate 86-90%) and inexpensive Antibiotic against various anaerobes and protozoa Oral dose 250mg qid for 7-10 days Relapse rate 8-9% of cases Contraindication: Children below 10yrs and women during pregnancy
- 6. Vancomycin Most reliable treatment (response rate 90-100%) Poorly absorbed (less side effects) There is risk of developing vancomycin-resistant enterococci Oral dose 125mg qid for 7-10 days In the setting of ileus, higher dose 500mg qid for 7-10 days to deliver adequate doses
- 7. Vancomycin Indications : Patients cannot tolerate or fail to respond to metronidazole Organisms resistant to metronidazole Patients less than 10yrs old or pregnant Patients who are critically ill due to C.difficile infection e.g toxic megacolon or colonic perforation
- 8. Relapses Not commonly associated with resistance to metronidazole Mostly occur 3-10 days after discontinuation of treatment Should be treated with second course of metronidazole Some authors report success in preventing relapses with tapering regimen of vancomycin given daily or every other day for 1-2 months For patients who do not respond to either regimen of metronidazole or vancomycin – combination of vancomycin and rifampicin – sometimes beneficial
- 9. Second line Therapy Bacitracin and teicoplanin (antibiotics) Anion-exchange binding resin (Cholestyramine) – binds cytotoxin of C.difficile – do not use together with vancomycin Repopulation of gut flora – ingestion of yeast Saccharomyces boulardii (in relapses ) NB: Antidiarrheal agent SHOULD BE AVOIDED because it will prolong mucosal exposure to toxin and this also applies to post-op narcotic anaelgesia
- 10. Surgical Intervention Indicated for patients who are complicated with toxic megacolon with existing or subsequent risk of perforation Frequency is low (0.39 – 3.6%) Diverting ileostomy or subtotal colectomy Colostomy/ileostomy- for direct instillation of antibiotics into the colon lumen in patients with ileus (rare) Early subtotal colectomy- in fulminant toxic cases that do not respond to treatment after 7 days due to increased risk of perforation Overall mortality rate for patients requiring surgery is 30-35%
- 11. Follow-up Care Not required however return of diarrhea may indicate the need for retreatment 10-20% of patients will have a relapse Prognosis If properly treated, it is a self-limiting disease with good prognosis Overall mortality rate is 2% Mortality rate in untreated elderly or debilitated patients = 10-20% Mortality rate in patients with toxic megacolon = 35%
- 12. References 1 . Pseudomembranous colitis: Surgical Perspective http://www.emedicine.com/med/topic 2743.htm 2. Harrison’s Principles of Internal Medicine 14 th Edition. McGraw-Hill Companies Inc.1998 3 Rang HP, Dale MM, Ritter JM. Pharmacology 3 rd Edition. Churchill Livingstone.1995