Pseudomembranous colitis - Treatment

Approaches to the treatment of pseudomembranous colitis and diarrhea caused by C. difficile are generally similar in adults and children, but there are certain differences that allow them to be considered separately in adults and children.

Adults If possible, the antibiotic that may have caused the colitis should be discontinued. In cases of moderate severity, this is usually sufficient. Improvement in the condition is observed within 48 hours after discontinuing the antibiotic, and diarrhea ends several days later. In more severe cases, additional treatment is necessary. High concentrations of the drug active against C. difficile in the intestine are achieved when it is administered orally or through a tube. If antibacterial therapy is required to treat infectious processes in other locations, an antibiotic active against C. difficile is included in the combined antibacterial therapy.

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Treatment of mild to moderate pseudomembranous colitis

Metronidazole is usually prescribed at a dose of 250 mg 4 times a day for 10-14 days. The cost of vancomycin for oral administration is significantly higher, in addition, this form has never been imported into the Russian Federation. Therefore, it is recommended to take orally a solution of the drug intended for intravenous administration in the same dosage as orally. Widespread use of the drug orally can lead to increased resistance of enterococci to vancomycin. This is why metronidazole is preferred in mild cases.

Treatment of severe pseudomembranous colitis

In cases of very severe or life-threatening infection, many experts recommend using vancomycin at a dose of 125 mg 4 times a day for 10-14 days. There is a general opinion on the need to reduce the consumption of vancomycin due to the high probability of increasing enterococcal resistance.

Bacitracin

It is used in a dose of 25,000 units or 500 mg 4 times a day for 10-14 days instead of metronidazole and vancomycin. The clinical efficacy is significantly lower. In addition, the drug is not available in the Russian Federation in the form for oral administration.

If oral administration is not possible, the optimal regimen is unknown. Preliminary data suggest advantages of intravenous metronidazole (500 mg q 6 h) over vancomycin, which is relevant in patients with intestinal obstruction. Additionally, oral vancomycin is administered via a tube, ileostomy, colostomy, or enema at a higher than usual dose (500 mg q 6 h). It is usually recommended to determine the level of vancomycin in the blood plasma to avoid its overdose.

Cholestyramine

Used in moderate to severe cases of the disease. It is capable of binding toxin B and possibly toxin A, thereby reducing their biological activity. Due to its ability to bind vancomycin, their combined use is not recommended.

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Lactobacillus acidophilus

The role of lactobacilli as replacement therapy is unclear and is therefore not recommended.

Opiates and antiperistaltic drugs

The drugs of these groups are contraindicated, they are especially dangerous for children, as they can contribute to the aggravation of the condition. This is due to the sequestration of fluid in the intestinal lumen, increased absorption of toxins in the colon. In this case, more significant lesions of the colon are noted.

Treatment of pseudomembranous colitis in children

If possible, the antibiotic therapy that caused the disease should be discontinued.

Vancomycin

In children with severe toxicosis or diarrhea, the main drug is vancomycin at a dose of 10 mg/kg orally every 6 hours for 10 days.

Metronidazole

Prescribed orally or intravenously 10 mg/kg every 6 hours orally or intravenously. The regimen has similar efficacy to vancomycin, but is significantly cheaper. The safety of this regimen in children has not been established, so it is not used in some countries.

Cholestyramine

It has not been studied for this indication in children and is therefore not recommended.

Treatment of recurrent infection following a course of antibacterial therapy. In 10-20% of patients, diarrhea recurs after treatment with vancomycin or metronidazole. In some cases, this may not be a recurrent infection, but a new infection with a different strain of C. difficile, as has been found in patients with mental disorders. In these cases, the optimal treatment tactics have not been determined. Usually, 7-14-day courses of metronidazole or vancomycin are used orally. Longer use of antibiotics does not eradicate C. difficile and does not prevent relapse. Short courses of antibacterial therapy allow for a more rapid restoration of normal intestinal flora, which usually suppresses the growth of C. difficile.

About 3% of clinically significant C. difficile strains may be resistant to metronidazole; resistance to vancomycin has not been detected. For the treatment of mild to moderate forms of the disease, a repeated course of metronidazole is usually prescribed. In severe cases, oral vancomycin is preferable. The treatment tactics for patients with life-threatening refractory infection have not been determined.

The role of colonization of the colon by ingestion of live lactobacilli has not been established. There are isolated reports of attempts to treat adult patients with capsules (1-2 capsules 3 times daily) containing about 500,000 lactobacilli each.

Another non-pathogenic biotherapeutic is live Saccharomyces boulardii, which has been used since the 1950s to treat diarrhea in Europe. More recent data from the US suggest that it is effective in treating diarrhea, but more clinical experience is needed, particularly for diarrhea caused by C. difficile.