Do Inflammatory Bowel Disease Patients Have Difficulty Tapering Off of Oral Vancomycin?

Abstract

Introduction: Antibiotic therapy has demonstrated efficacy in the short and long-term treatment of inflammatory bowel disease (IBD) colitis, however broad spectrum antibiotics may predispose to C. difficile infection (CDI). Oral vancomycin has been used successfully in the treatment of CDI in IBD, but patients frequently relapse after short course (14 day) therapy. There is limited data regarding prolonged use of this antibiotic beyond 2 weeks in IBD patients with and without CDI. We describe patterns of oral vancomycin treatment in a prospective IBD cohort, focusing on individuals who required prolonged treatment. Methods: Prescriptions for oral vancomycin in consented IBD patients from a prospective natural history registry were identified between 2009 and 2012. Individuals with oral vancomycin treatment beyond 3 months formed the study population (v-IBD). Demographic, clinical, and treatment parameters were characterized in each v-IBD study patient and compared with 5 non-vancomycin exposed IBD matched controls. Results: Of 1,748 IBD registry patients, 160 (9.2%) received oral vancomycin between 2009 and 2012 (vancomycin exposed). Vancomycin was used for >4 weeks in 68 individuals (42.5% of vancomycin exposed IBD) and 26 patients (16.2% of vancomycin exposed) received vancomycin for >3 months (v-IBD group). The duration of treatment in v-IBD patients ranged from 3.5-60 months. In the v-IBD patients, 20 (76.9%) were on vancomycin continuously for >6 months, 15 (57.7%) for >12 months, 8 (33.3%) for >24 months and 5 (19.2%) for >36 months. In the v-IBD group, 57.7% were female compared to 54.6% female in the control IBD subgroup (p=NS). There was no difference in disease subtype in v-IBD (57.7% Crohn’s disease) and controls (55.4% Crohn’s disease). All v-IBD patients demonstrated benefit from treatment based on improvement in SIBDQ scores. One-third of the v-IBD patients were diagnosed with CDI prior to oral vancomycin initiation. When compared with IBD controls (n=130), v-IBD patients (n=26) required more prednisone (84.6% vs. 37.7%; p<0.001), but demonstrated similar rates of immunomodulator use (48.5% vs. 65.4%; p=0.135), and anti-TNF biologic treatment (38.5% vs. 57.7%; p<0.083). No infections with vancomycin resistant bacteria were noted in the v-IBD patients. Conclusion: Oral vancomycin use is common in IBD with 1 in 11 patients receiving this antibiotic over 4 years. Among vancomycin treated IBD patients >40% received treatment for at least 1 month continuously. A subgroup of refractory IBD patients who had high rates of steroid, immunomodulator, and anti-TNF use benefited from maintenance oral vancomycin beyond 3 months. Prospective evaluation of oral vancomycin in IBD patients is warranted.