DOI QR코드

DOI QR Code

내과계 중환자실 재원 성인 환자의 Clostridium difficile associated Diarrhea에 대한 Metronidazole과 Vancomycin의 치료효과 비교

A Comparison of Vancomycin and Metronidazole for the Treatment of Clostridium difficile-associated Diarrhea (CDAD) in Medical Intensive Care Unit (MICU)

  • 조은애 (연세대학교 세브란스병원 약무국) ;
  • 이경아 (연세대학교 세브란스병원 약무국) ;
  • 김재송 (연세대학교 세브란스병원 약무국) ;
  • 김수현 (연세대학교 세브란스병원 약무국) ;
  • 손은선 (연세대학교 세브란스병원 약무국)
  • Cho, Eun Ae (Department of Pharmacy, Yonsei University Health System) ;
  • Lee, Kyung A (Department of Pharmacy, Yonsei University Health System) ;
  • Kim, Jae Song (Department of Pharmacy, Yonsei University Health System) ;
  • Kim, Soo Hyun (Department of Pharmacy, Yonsei University Health System) ;
  • Son, Eun Sun (Department of Pharmacy, Yonsei University Health System)
  • 투고 : 2017.03.06
  • 심사 : 2017.05.18
  • 발행 : 2017.06.30

초록

Background: Clostridium difficile associated diarrhea (CDAD) is a leading cause of hospital-associated gastrointestinal illness. Risk factors for CDAD include advanced age, long-term admission, antibiotics, proton-pump inhibitor or $H_2$ blocker use and immunosuppression. The practice guideline of American Journal of Gastroenterology (2013) suggests metronidazole for the first-line therapy of mild-moderate CDAD as well as vancomycin for severe CDAD. MICU inpatients receiving stress ulcer prophylaxis and antibiotics are susceptible to nosocomial CDAD. Therefore, this study aimed to evaluate occurrence and treatment of CDAD in MICU. Methods: Patients who were admitted to the MICU and had CDAD from August 2012 to August 2015 were analyzed retrospectively. Results: Of the 90 patients with CDAD, 20 patients (2.22%) had mild-moderate CDAD (16 received metronidazole and 4 received vancomycin therapy) and 70 patients (77.8%) had severe CDAD(54 received metronidazole and 16 received vancomycin therapy). Among the patients with mild- moderate CDAD, treatment with metronidazole or vancomycin resulted in same clinical cure in 50% of the patients (p=1.00). Among the patients with severe CDAD, treatment with metronidazole or vancomycin resulted in clinical cure in 40.7% and 50.0% of the patients, respectively (p=0.511). Clinical symptoms recurred in 7.4% of the severe CDAD patients treated with metronidazole and 6.3% of those treated with vancomycin(p=0.875). Conclusion: Our findings suggest that metronidazole and vancomycin are equally effective for the treatment of mild-moderate CDAD; however, vancomycin demonstrated higher clinical cure rate and lower recurrence rate for severe CDAD, although the difference was not statistically significant. For better clinical outcomes, appropriate medication use by disease severity is needed.

키워드

참고문헌

  1. Larson H.E., Price A.B., Honour P. et al. Clostridium difficile and the etiology of pseudomembranous colitis. The Lancet 1978;311(8073):1063-1066. https://doi.org/10.1016/S0140-6736(78)90912-1
  2. Bartlett J.G. Clostridium difficile: clinical considerations. Rev Infect Dis 1990;12(Suppl 2):S243-51. https://doi.org/10.1093/clinids/12.Supplement_2.S243
  3. Kelly C.P., Pothoulakis C. and LaMont J.T. Clostridium difficile colitis. N Engl J Med 1994;330(4):257-62. https://doi.org/10.1056/NEJM199401273300406
  4. Monaghan T., Boswell T. and Mahida Y.R. Recent advances in clostridium difficile- associated disease. Gut 2008;57(6):850-60.
  5. Cohen S.H., Gerding D.N., Johnson S. et al. Clinical practice guidelines for clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol 2010;31(5):431-55. https://doi.org/10.1086/651706
  6. Kelly C.P., LaMont J.T. Clostridium difficile-more difficult than ever. N Engl J Med 2008;359(18):1932-40. https://doi.org/10.1056/NEJMra0707500
  7. Bartlett J.G. Clinical practice. Antibiotic-associated diarrhea. N Engl J Med 2002;346(5):334-39. https://doi.org/10.1056/NEJMcp011603
  8. Teasley D.G., Gerding D.N., Olson M.M. et al. Prospective randomised trial of metronidazole 1983;2(8358):1043-46.
  9. Wenisch C., Parschalk B., Hasenhundl M. et al. Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of clostridium difficile-associated diarrhea. Clin Infect Dis 1996;22(5):813-18. https://doi.org/10.1093/clinids/22.5.813
  10. Musher D.M., Aslam S., Logan N. et al. Relatively poor outcome after treatment of clostridium difficile colitis with metronidazole. Clin Infect Dis 2005;40(11):1586-90. https://doi.org/10.1086/430311
  11. Pepin J., Alary M.E., Valiquette L. et al. Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada. Clin Infect Dis 2005;40(11):1591-97. https://doi.org/10.1086/430315
  12. Aslam S., Hamill R.J. and Musher D.M. Treatment of clostridium difficile-associated disease: old therapies and new strategies. Lancet Infect Dis 2005;5(9):549-57. https://doi.org/10.1016/S1473-3099(05)70215-2
  13. Zar F.A., Bakkanagari S.R., Moorthi K.M. et al. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis 2007;45(3):302-7. https://doi.org/10.1086/519265
  14. Hookman P., Barkin J.S. Clostridium difficile associated infection, diarrhea and colitis. World J Gastroenterol 2009;15(13):1554-80. https://doi.org/10.3748/wjg.15.1554
  15. Yoo-jung Choi Y.-s.C., Hye-sook Lee, Hyang-sook Kim et al. Evaluation of oral vancomycin use for the treatment of clostridium difficile-associated disease and risk factor analysis of treatment failure. J. Kor. Soc. Health-Syst. Pharm 2013;30(3):194-201.
  16. Korea pharmaceutical information Center. Drug information. Available from http://drug.mfds.go.kr/html.indes.jsp. Accessed March 23, 2017.
  17. Korea pharmaceutical information Center. Drug information. Available from http://drug.mfds.go.kr/html/bxsSearchDrugProduct.jsp?item_Seq=199801540. Accessed March 23, 2017.
  18. Al-Nassir W.N., Sethi A.K., Nerandzic M.M. et al. Comparison of clinical and microbiological response to treatment of clostridium difficile-associated disease with metronidazole and vancomycin. Clin Infect Dis 2008;47(1):56-62. https://doi.org/10.1086/588293
  19. Clements A.C., Magalhaes R.J., Tatem A.J. et al. Clostridium difficile PCR ribotype 027:assessing the risks of further worldwide spread. Lancet Infect Dis 2010;10(6):395-404. https://doi.org/10.1016/S1473-3099(10)70080-3
  20. Lee Y.J., Choi M.G., Lim C.H. et al. Change of clostridium difficile colitis during recent 10 years in Korea. Korean J Gastroenterol 2010;55(3):169-74. https://doi.org/10.4166/kjg.2010.55.3.169
  21. Loo V.G., Poirier L., Miller M.A. et al. A predominantly clonal multiinstitutional outbreak of clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med 2005;353(23):2442-449. https://doi.org/10.1056/NEJMoa051639
  22. Yip C., Loeb M., Salama S. et al. Quinolone use as a risk factor for nosocomial clostridium difficile-associated diarrhea. Infect Control Hosp Epidemiol 2001;22(9):572-75. https://doi.org/10.1086/501954