Metronidazole failure in treatment of community acquired Clostridum Difficile Colitis in Inflammatory Bowel Disease patients: A Case Series

Abstract

Inflammatory bowel disease (IBD) is an independent risk factor for Clostridium difficile associated colitis (CDAC), occurring more often in ulcerative colitis (UC) compared to Crohn's disease (CD). IBD outpatients in clinical remission have increased frequency of detectable fecal C. difficile when compared to healthy adults. Increased frequency and severity of CDAC may be related to a highly virulent C. difficile strain. We present four cases of CDAC in IBD outpatients that were refractory to Metronidazole. These cases support consideration for early Vancomycin treatment in IBD. A 6 month retrospective review of medical records from an outpatient universitybased practice identified four cases of CDAC in IBD patients. CASE 1: A 31-year-old female with an 8 year history of UC maintained on mesalamine presented with fever, bloody diarrhea, urgency, tenesmus, and abdominal cramping. She received recent treatment with Ciprofloxacin for a sinus infection. C. difficile toxin was detected in stool samples. Metronidazole and Lactobacillus GG were initiated resulting in minimal response after 10 days. Metronidazole was discontinued and Vancomycin was initiated. Within one week, the patient had clinical improvement, with resolution occurring after 6 weeks. CASE 2: A 31-year-old male with a 2 year history of UC, maintained on infliximab and oral mesalamine presented with 1 week of abdominal cramping and bloody diarrhea following a 7-day course of Amoxicillin for a dental procedure. C. difficile toxin was detected in stool samples. There was no improvement after 1 week of Metronidazole. Vancomycin resulted in clinical improvement within 7 days. CASE 3: A 32-year-old male with an 18 year history of UC controlled with oral and rectal mesalamine presented with bloody diarrhea, urgency, abdominal pain, and fevers. C. difficile toxin was detected in stool samples. The patient was treated for 9 days with Metronidazole without improvement. Three weeks of oral Vancomycin resulted in symptom resolution. CASE 4: A 48-year-old female with a 25 year history of ileal CD maintained in remission on Azathioprine and Ciprofloxacin presented with diarrhea following a recent hospitalization for partial small bowel obstruction managed non-operatively. She was discharged on a 10 day course of empiric Metronidazole. Stool samples detected C. difficile toxin, and she was treated with Vancomycin. Symptoms improved after one week of therapy with complete resolution after 3 weeks. All patients identified were initially treated with Metronidazole, with minimal or no clinical improvement. Subsequent treatment with oral Vancomycin resulted in rapid improvement and eventual resolution of CDAC. IBD patients are at increased risk for community and hospital-acquired CDAC. Reports have suggested that IBD patients with CDAC may have limited improvement with Metronidazole. Oral Vancomycin is indicated in IBD patients failing to respond to Metronidazole within 48 hours as outpatients or when hospitalized with fulminant colitis. Since Vancomymcin has a superior response rate and a lower recurrence rate of C. difficile infection, it may be an appropriate first line therapy for IBD patients with CDAC. Studies should be conducted to determine optimal therapy of CDAC in IBD.