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Does Addition of Intravenous Metronidazole to Oral Vancomycin Improve Outcomes in Clostridioides difficile Infection?

Ying Wang1, Aaron Schluger2, Jianhua Li1

  • 1Department of Medicine, Columbia University Medical Center, New York, New York, USA.

Clinical Infectious Diseases : an Official Publication of the Infectious Diseases Society of America
|November 13, 2019
PubMed
Abstract

Insights

Adding intravenous metronidazole to vancomycin for Clostridioides difficile infection (CDI) did not improve outcomes. This dual therapy was common but showed no benefit over vancomycin monotherapy for fulminant or nonfulminant CDI.

Area of Science:

  • Infectious Diseases
  • Pharmacology
  • Clinical Medicine

Background:

  • Current guidelines suggest intravenous metronidazole plus oral vancomycin for severe Clostridioides difficile infection (CDI).
  • This study investigated the use and effectiveness of this dual therapy compared to vancomycin monotherapy.
  • The research focused on both nonfulminant and fulminant cases of CDI.

Purpose of the Study:

  • To compare the effectiveness of dual therapy (IV metronidazole and vancomycin) versus vancomycin monotherapy in patients with Clostridioides difficile infection (CDI).
  • To assess the prevalence of dual therapy use in nonfulminant and fulminant CDI.
  • To determine if dual therapy is associated with improved outcomes or reduced recurrence compared to vancomycin alone.

Main Methods:

  • A retrospective study analyzed adult inpatients with positive C. difficile PCR tests from 2010 to 2018 at two centers.
  • Patients receiving vancomycin within two days of testing were classified into dual therapy (if IV metronidazole was also given) or vancomycin monotherapy groups.
  • The primary outcome was 90-day death or colectomy, with CDI recurrence examined as a secondary outcome, using logistic regression for adjusted analyses.

Main Results:

  • The study included 2114 patients, with 23% experiencing the primary outcome (death or colectomy within 90 days).
  • Dual therapy was not associated with the primary outcome in the overall cohort (aOR 1.07) or in patients with fulminant CDI (aOR 1.17).
  • No significant association was found between dual therapy and CDI recurrence.

Conclusions:

  • Dual therapy with intravenous metronidazole and vancomycin is frequently used for both nonfulminant and fulminant Clostridioides difficile infection.
  • This combination therapy did not demonstrate improved clinical outcomes or reduced recurrence compared to vancomycin monotherapy.
  • The findings suggest that current guidelines recommending this dual therapy for severe CDI may not be supported by this study's evidence.
Keywords:
Clostridioides difficile infectionClostridioides difficile infection outcomesfulminant Clostridioides difficile infectionmetronidazolevancomycin

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