Diarrhea vancomycin

MANAGING DIARRHEA. Diarrhea may be a sign of a superinfection or pseudomembranous colitis, both of which are adverse reactions tiiat may be seen with the administration of any anti-infective. The nurse checks each stool and reports any changes in color or consistency. When vancomycin is given as part of the treatment for pseudomembranous colitis, it is important to record the color and consistency of each stool to determine the effectiveness of therapy. 

Progress in defining new treatments for C. difficile infection has been hindered by the heterogeneous nature of hospital-acquired diarrhea, and in particular by whether colitis and/or pseudomembranous colitis is present in individual cases. Study groups have usually been poorly defined in this context, and given the spontaneous resolution of symptoms in a proportion of cases the true efficacy of treatment approaches often remains uncertain. Enthusiasm to explore new treatment possibilities for C. difficile has been largely fuelled by the apparently high relapse rate of conventional (metronidazole or vancomycin) treatment [138],... 

Wenisch C, Parschalk B, Hasenhundl M, Hirschl AM, Graninger W Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of Clostridium difficile-associated diarrhea. Clin Infect Dis 1996 22 813-818. 

Common adverse effects are diarrhea, nausea, and skin rashes. Impaired liver function (with or without jaundice) and neutropenia sometimes occur. Severe diarrhea and enterocolitis have followed clindamycin administration. Antibiotic-associated colitis that has followed administration of clindamycin and other drugs is caused by toxigenic C difficile. This potentially fatal complication must be recognized promptly and treated with metronidazole, 500 mg orally or intravenously three times a day (the preferred therapy), or vancomycin, 125 mg orally four times a day (less desirable given the increasing prevalence of vancomycin-resistant enterococci). Relapse may occur. 

Diarrhea occurs in a few patients taking albendazole and is usually mUd. However, a typical case of pseudomembranous colitis has been documented, although the patient also had AIDS and intestinal microsporidiosis and had taken a number of other drugs the complication responded to vancomycin (30). 

The role of anion exchange resins (colestyramine and colestipol), which bind C. difficile toxin, is still controversial (172). If ion exchange resins are given at all, they should not be given together with vancomycin, because they also bind the antibiotic (173). Attempts to restore the intestinal flora with Lactobacillus GG (174), or with fecal enemas (175) from healthy volunteers have shown some favorable results in less severe cases. However, esthetic and infectious concerns may be an obstacle. It also has been suggested that treatment with Saccharomyces bou-lardii may help prevent the development of antibiotic-associated diarrhea (176). Its value in the prevention and treatment of relapses has still to be demonstrated. Antimotility agents have been associated with an increased incidence of antibiotic-related diarrhea and can worsen symptoms when the disease is already estab-hshed (177). They should therefore be avoided. 

Buggy BP, Fekety R, Silva J Jr. Therapy of relapsing Clostridium difficile-associated diarrhea and colitis with the combination of vancomycin and rifampin. J Clin Gastroenterol 1987 9(2) 155-9. 

In two cases the diarrhea and colitis associated with fluorouracil therapy were caused by toxigenic Clostridium difficile. Both patients responded to oral vancomycin (95). 

A 29-year-old man was given mycophenolate and tacrolimus for an episode of renal transplant rejection that occurred 6.5 years after transplantation. Four weeks after tacrolimus was begun, he had diarrhea, nausea, and malaise. There was C. difficile toxin in the stools, and his symptoms abated with metronidazole. About 1 month later, he developed diarrhea, fever, and severe dehydration. Clostridium difficile toxin was again detected in the stools, and his symptoms completely resolved with oral vancomycin and withdrawal of tacrolimus. 

In a randomized, prospective, cost-effectiveness study both teicoplanin and vancomycin were assessed as second-line therapy in 66 neutropenic patients after the failure of empirical treatment with a combination of piperacillin -I- tazobactam and amikacin (10). The primary success of second-line therapy was equivalent, and the direct total costs were similar. Acquisition costs per dose were in favor of vancomycin, but costs derived from administering vancomycin and serum concentration monitoring led to similar costs for both regimens. With the exception of the red man syndrome, which occurred in 10% of vancomycin-treated patients but none of the tei-coplanin-treated patients, toxicity (renal, liver, and ear toxicity, diarrhea, phlebitis) was also similar. 

The most common adverse events associated with teicoplanin are hypersensitivity, fever, rash, diarrhea, nephrotoxicity, and thrombocytopenia (12,13). Local reactions at the injection site include pain, redness, or discomfort after intramuscular injection, or phlebitis after intravenous injection. Erythroderma has occurred during infusion of teicoplanin with fever and hypotension. Allergic reactions have been reported with teicoplanin, with cross-reactivity between teicoplanin and vancomycin documented by in vitro studies showing IgE release by basophils in response to stimulation by both vancomycin and teicoplanin. However, known hypersensitivity to vancomycin is not a contraindication to teicoplanin. Tumor-inducing effects have not been reported. 

Antibiotic-associated diarrhea can develop with any antibacterial agent. Vancomycin has been implicated as a rare cause of diarrhea associated with Clostridium difficile (56), despite the fact that vancomycin is often used to treat it. 

Diarrhea developed in a 60-year-old man on chronic hemodialysis after 20 doses of parenteral vancomycin (250 mg at each dialysis) (57). Although culture for C. difficile was not performed, latex agglutination was positive for C. difficile toxin. 

A few other cases of antibiotic-associated diarrhea with vancomycin have been described in association with C. difficile. This paradoxical association, although very uncommon, should be considered in patients who develop diarrhea during vancomycin therapy. 

Schenfeld LA, Pote HH Jr. Diarrhea associated with parenteral vancomycin therapy. Chn Infect Dis 1995 20(6) 1578-9. 

B Antibiotic-associated diarrhea due to C difficile can occur with any antibiotic, but particularly with clindamycin. With the administration of antibiotics, normal Gl flora is inhibited, which allows C. difficile to overgrow. Metronidazole is the treatment of choice for C. difficile infections. Although oral vancomycin also has activity against C. difficile, it is typically used as second-line treatment... 

Initial therapy should include discontinuation of the offending agent with a change to an alternative antibiotic if possible. Fluid and electrolyte replacement therapy is necessary. Although diarrhea will resolve in 15% to 23% of patients without therapy, most patients will require antibiotics. Both vancomycin and metronidazole are effective, but metronidazole 250 mg orally four times daily is the drug of choice. It is similar to vancomycin in time to resolution of diarrhea, incidence of side effects, and relapse rates. However, it is less expensive than vancomycin, and the concern for vancomycin resistance promotes metronidazole use. 

Oral vancomycin 125 mg four times daily is second-line therapy. Its use is appropriate in the following situations The patient has not responded to oral metronidazole the organism is resistant to metronidazole the patient is allergic or intolerant to metronidazole treatment includes ethanol-containing solutions the patient is either pregnant or younger than 10 years of age the patient is critically ill because of C. difficile diarrhea or colitis (the duration of diarrhea is reduced... 

Vancomycin is the drug of choice against serious infections caused by methicihin-resistant strains of Staphylococcus aureus and coagulase-negative staphylococci [172]. It may also be used for treatment of infections by gram-positive organisms in penicillin-intolerant patients. Vancomycin has been extensively used to treat endocarditis caused by streptococci, enterococci and staphylococci. The empiric treatment of intravenous catheter sepsis and hemodialysis vascular access infection by vancomycin has led to a linear increase in its use in the last decade [173]. Oral vancomycin is efficacious in the treatment of Corynebacterium difficile-mediated diarrhea. Of major concern is the recent emergence of vancomycin-resistant enterococcus strains [174,175]. 

The tetracyclines administered orally or parenterally may lead to the development of superinfections caused by strains of bacteria or fungi resistant to these agents. Pseudomembranous colitis due to overgrowth of toxin-producing C. difficile presents with severe diarrhea, fever, and stools containing mucous membrane neutrophils. Discontinuation of the drug, combined with the oral administration of metronidazole or vancomycin, usually is curative. 

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