A Durable Response to Relapsing Clostridium difficile Colitis May Require Combined Therapy with High-dose Oral Vancomycin and Intravenous Immune Globulin

摘要

Background: Recurrent Clostridium difficile antimicrobial-induced diarrhea follows initial successful therapy with metronidazole or oral vancomycin in 5% to 65% of patients. Specific antibody formation to Toxin A of C. difficile has been found in those patients who remain asymptomatic or experience a single episode of diarrhea after their initial infection. Because those individuals who often cannot produce specific antibody develop relapsing colitis, we administered intravenous immune globulin (IVIG) to 20 such hospitalized patients and evaluated their responses. Materials and Methods: C difficile immunoglobulin G antibody was measured in 18 of 20 patients with recurrent colitis using an enzyme-linked immunosorbent assay. All patients were subsequently placed on oral vancomycin (dosage, 500 mg 3 times a day) and 2 doses of IVIG (dosage, 30 g within 24 to 96 hours after antibody levels were drawn). The time interval between both doses was about 24 hours. Results: Eighteen of 20 patients had a durable response to the previously mentioned therapy, of which 1 case recurred within a 3-month follow-up period. Two patients responded to therapy but died of underlying or associated disease (one of pneumonia and one of congestive heart failure). Ten patients also received oral Saccharomy-ces boulardii, a nonpathogenic yeast One of these patients died of heart failure and another had a recurrent disease. Conclusions: IVIG and high-dose oral vancomycin may be an effective regimen in eradicating relapsing C. difficile colitis, probably confirming the suspicion that patients who develop the disease lack the ability to produce adequate quantities of neutralizing immunoglobulin G antibody against Toxin A Oral 5!. boulardii may help maintain freedom from relapse, which, however, was not confirmed in this study, and its use could be complicated by fungemia.