Pseudomembranous colitis treatment

Pseudomembranous colitis Treatment with antibacterial agents alters the normal flora of the colon and may permit overgrowth of Clostridia. Pseudomembranous colitis has been reported with nearly all antibacterial agents. 

Pseudomembranous colitis may occur after 4 to 9 days of treatment with penicillin or as long as 6 weeks after the drug is discontinued. 

DIARRHEA. Frequent liquid stools may be an indication of a superinfection or pseudomembranous colitis. If pseudomembranous colitis occurs, it is usually seen 4 to 10 days after treatment is started. 

The nurse inspects each bowel movement and immediately reports to the primary health care provider the occurrence of diarrhea or loose stools containing blood and mucus because it may be necessary to discontinue the drug use and institute treatment for diarrhea, a superinfection, or pseudomembranous colitis. 

Like the other anti-infectives, bacterial or fungal superinfections and pseudomembranous colitis (see Chap. 7) may occur with the use of these drags. The administration of the aminoglycosides may result in a hypersensitivity reaction, which can range from mild to severe and in some cases can be life threatening. Mild hypersensitivity reactions may only require discontinuing the drug, whereas the more serious reactions require immediate treatment. 

Vancomycin (Vancocin) acts against susceptible gram-positive bacteria by inhibiting bacterial cell wall synthesis and increasing cell wall permeability. This drug is used in the treatment of serious gram-positive infections that do not respond to treatment with other anti-infectives. It also may be used in treating anti-infective-associated pseudomembranous colitis caused by Clostridium difficile. 

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. 

Employed as the hydrochloride and administered by dilute intravenous injection, vancomycin is indicated in potentially life-threatening infections that cannot be treated with other effective, less toxic, antibiotics. Oral vancomycin is the drug of choice in the treatment of antibiotic-induced pseudomembranous colitis associated with the administration of antibiotics such as clindamycin and lincomycin (section 9.3). 

Although their effectiveness is similar to the tetracyclines, the use of erythromycin and clindamycin is often limited due to their potential adverse outcomes. Erythromycin has treatment failure due to resistance and a high incidence of gastrointestinal intolerance, while clindamycin causes diarrhea and carries a risk of developing pseudomembranous colitis with long-term use.3,8... 

Monitor the patient for the development of potential complications of treatment such as delayed hypersensitivity reactions, antibiotic-induced diarrhea, pseudomembraneous colitis, or fungal superinfections (manifested as oral thrush). 

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],... 

A randomized open trial, performed in patients with C. difficile pseudomembranous colitis, compared rifaximin (200 mg 3 times daily) to vancomycin (500 mg 2 times daily) and found the two drugs similarly effective [141]. The clearance of bacterial toxins was, however, more rapid with vancomycin. Further large double-blind clinical studies are needed to better define the role of rifaximin in the treatment of C. difficile infection. 

Resistance As with other -lactam antibiotics, some strains of P. aeruginosa may develop resistance fairly rapidly during treatment with imipenem-cilastatin. Pseudomembranous colitis Pseudomembranous colitis has occurred with virtually all antibiotics. 

Pseudomembranous colitis If suspected, stop rifapentine immediately and treat the patient with supportive and specific treatment without delay (eg, oral vancomycin). Products inhibiting peristalsis are contraindicated in this clinical situation. HIV-Infected patients As with other antituberculosis treatments, when rifapentine is... 

However the reported adverse effects include mild gastrointestinal reactions (nausea, vomiting, abdominal cramps and diarrhoea). Symptoms of pseudomembranous colitis may appear either during or after antibiotic treatment. The other side effects are allergic in nature viz. skin rash, itching, bronchospasm, hypotension, erythema multiforme, Steven-Johnson syndrome. Other side effects viz. haemolytic anaemia, hypoprothrombine-mia, seizures and thrombophlebitis have been rarely reported. 

Serious and occasionally fatal anaphylactoid reactions have been reported in patients on penicillin therapy Serious anaphylactoid reactions require immediate emergency treatment with epinephrine Pseudomembranous colitis has been reported... 

Clostridium difficile is a commensal Gram-positive anaerobic bacterium of the human intestine, found in about 2-5% of the population. C. difficile is the most serious cause of antibiotic-associated diarrhoea and can lead to pseudomembranous colitis, a severe infection of the colon, often resulting from eradication of the normal gut flora by antibiotics. Discontinuation of causative antibiotic treatment is often curative. In more serious cases, oral administration of metronidazole or vancomycin is the treatment of choice. The bacterium produces several known toxins, including enterotoxin (toxin A) and cytotoxin (toxin B), both of which are responsible for the diarrhoea and inflammation seen in infected patients another toxin, binary toxin, has also been described. 

Because of its potential toxicity, vancomycin is reserved for serious infections in which less toxic antibiotics are ineffective or not tolerated. Generally, vancomycin is administered intravenously because of poor intestinal absorption. It is the drug of choice for treating infections caused by methicillin-resistant staphylococci and penicillin-resistant Streptococcus pneumoniae. Vancomycin has been used to treat enterococcal infections because of their resistance to the P-lactam antibiotics, but most enterococci are now also resistant to vancomycin. Oral administration of rancomycin is important for treatment of some gastrointestinal infections such as pseudomembranous colitis caused by C. difficile. 

An acute colitis, different from pseudomembranous colitis, was observed in five patients taking penicillin and penicillin derivatives (133). There was considerable rectal bleeding. The radiographic findings were those of ischemic colitis (spasm, transverse ridging, thumbprinting, and punctuate ulceration). On sigmoidoscopy and biopsy, the mucosa was normal, except for an inflammatory cell infiltration in one case. Conservative treatment resulted in rapid remission. 

The appearance of pseudomembranous colitis in clusters of patients (143-146) may explain the wide variation in occurrence, and suggests that the disease may result from cross-contamination among patients rendered susceptible by antibiotic treatment. This is especially true for epidemic outbreaks in hospitals, where the disease may be considered a nosocomial infection favored by serious illness, frequent and prolonged use of broad-spectrum antibiotics (especially cephalosporins), and poor compliance with the rules of hospital hygiene (147). In such an epidemic, a variable proportion of... 

Although the first antibiotics reported to cause pseudomembranous colitis were lincomycin and clindamycin, the disease was later described with all other antimicrobial drugs, even topically applied (149). Vancomycin (150) and metronidazole (151), which may be used as specific treatments, have also been implicated. 

Therapy consists of withdrawal of the antibiotic when diarrhea occurs and replacement of fluid and electrolyte losses. In less severe cases of antibiotic-associated diarrhea, no further treatment is needed. However, in patients with pseudomembranous colitis, a more intensive approach is usually required. When a toxic syndrome develops, fluid losses within the bowel can be very large. In these cases, a central venous line offers the chance to measure central venous pressure. Usually there is also loss of serum proteins and in some cases blood, which need appropriate replacement. In the rare cases with fulminant colitis and toxic megacolon, surgical intervention may be necessary (165,166). 

In pseudomembranous colitis (typical endoscopic findings, positive test for C. difficile or its toxin), the preferred treatment is oral metronidazole, 250 mg qds or 500 mg tds (120,167). Metronidazole is as effective as vancomycin 125-250 mg qds, which is significantly more expensive (168). Oral bacitracin 25 000 U qds (169) and oral teico-planin (170) are acceptable alternatives. 

Van Ness MM, Cattau EL Jr. Fulminant colitis complicating antibiotic-associated pseudomembranous colitis case report and review of the clinical manifestations and treatment. Am J Gastroenterol 1987 82(4) 374-7. 

Bartlett JG. Treatment of antibiotic-associated pseudomembranous colitis. Rev Infect Dis 1984 6(Suppl 1) S235 1. 

Ariano RE, Zhanel GG, Harding GK. The role of anion-exchange resins in the treatment of antibiotic-associated pseudomembranous colitis. CMAJ 1990 142(10) 1049-51. 

Pseudomembranous colitis has been reported in an 86-year-old woman with non-ulcer dyspepsia a few days after she had taken triple eradication therapy (omeprazole 20 mg bd, metronidazole 400 mg tds, and clarithromycin 500 mg bd) she recovered after treatment with oral vancomycin (14). 

In a multicenter, open, randomized trial in 204 patients with erysipelas treated with either oral pristinamycin 1 g tds or intravenous then oral penicillin, adverse events related to treatment were significantly more common with pristinamycin they were mostly mild or moderate and mainly involved the gastrointestinal tract (33). Pristinamycin can cause pseudomembranous colitis. 

Vancomycin hydrochloride is always administered intravenously (never intramuscularly), either by slow injection or hy continuous infusion, for the treatment of systemic infections. In shott-term therapy, the toxic side reactions arc usually slight, hut continued u.sc may lead to impaired auditory acuity, renal damage, phlebitis, and rashes. Bccau.se it is nut assorted or signilicantly degraded in the gastrointc.stinal tract, vancomycin may he administered orally fur the treatment of staphylococcal enterocolitis and for pseudomembranous colitis associated with clindamycin therapy. Some conversion to aglucovancomycin likely (Kcurs in the low pH of the stomach. The latter retains about three-fourths of the activity of vancomycin. 

Abnormalities of liver, renal, and hematological parameters have been reported. As with other antibiotic regimens, pseudomembranous colitis may occur during or after treatment. Fluoroquinolones have the potential to cause adverse effects on developing cartilage and bone thus, ciprofloxacin should be used with caution in pregnant women and young children. 

Clindamycin is very effective in the treatment of acne, but has disadvantages for long-term therapy due to the possible induction of pseudomembranous colitis. For this reason, its use in acne is uncom-... 

Answer E. Vancomycin is usually considered to be a backup drug to metronidazole in colitis due to Clostridium difficile on the grounds that it is no more effective, is more costly, and should be reserved for treatment of resistant gram-positive coccal infections. None of the other drugs has activity in pseudomembranous colitis—indeed, they may cause it ... 

Diphenoxylate is an opiate (schedule V) with antidiarrheal properties. It is usually dispensed with atropine and sold as Lomotil. The atropine is added to discourage the abuse of diphenoxylate by narcotic addicts who are tolerant to massive doses of narcotic but not to the CNS stimulant effects of atropine. Diphenoxylate shonld be used cautiously in patients with obstructive jaundice because of its potential for hepatic coma, and in patients with diarrhea cansed by pseudomembranous colitis because of its potential for toxic megacolon. In addition, it should be used cautiously in the treatment of diarrhea caused by poisoning or by infection by Shigella, Salmonella, and some strains of E. coli because expulsion of intestinal contents may be a protective mechanism. Diphenoxylate should be used with extreme caution in patients with impaired hepatic function, cirrhosis, advanced hepatorenal disease, or abnormal liver function test results, because the drug may precipitate hepatic coma. Because diphenoxylate is structurally related to meperidine, it may cause hypertension when combined with monoamine oxidase inhibitors. As a narcotic, it will augment the CNS depressant effects of alcohol, hypnotic-sedatives, and numerous other drugs, such as neuroleptics or antidepressants that cause sedation. 

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