10. The Management Of Pseudomembranous Colitis


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10. The Management Of Pseudomembranous Colitis

  1. 1. Pseudomembranous colitis is a disease commonly associated with hospitalisation or prior antibiotic exposure Results from an inflammatory reaction of the bowel wall to the luminal toxin produced by Clostridium difficile
  2. 2. Discontinuation of antibiotics or other potentially inciting agents Supportive care for diarrhea i.e fluid repletion and electrolyte balance 25% of cases resolve without further treatment Isolation precautions i.e proper handwashing and disinfections
  3. 3. Specific for Clostridium difficile First line therapy – Oral metronidazole, oral vancomycin Second line therapy – Oral bacitracin, Teicoplanin, Fusidic acid, Anion exchange resin agents Surgical intervention
  4. 4. Effective (response rate 86-90%) and inexpensive Antibiotic against various anaerobes and protozoa Oral dose 250mg qid for 7-10 days Relapse rate 8-9% of cases Contraindication: Children below 10yrs and women during pregnancy
  5. 5. Most reliable treatment (response rate 90-100%) Poorly absorbed (less side effects) There is risk of developing vancomycin-resistant enterococci Oral dose 125mg qid for 7-10 days In the setting of ileus, higher dose 500mg qid for 7-10 days to deliver adequate doses
  6. 6. Indications : Patients cannot tolerate or fail to respond to metronidazole Organisms resistant to metronidazole Patients less than 10yrs old or pregnant Patients who are critically ill due to C.difficile infection e.g toxic megacolon or colonic perforation
  7. 7. Not commonly associated with resistance to metronidazole Mostly occur 3-10 days after discontinuation of treatment Should be treated with second course of metronidazole Some authors report success in preventing relapses with tapering regimen of vancomycin given daily or every other day for 1-2 months For patients who do not respond to either regimen of metronidazole or vancomycin – combination of vancomycin and rifampicin – sometimes beneficial
  8. 8. Bacitracin and teicoplanin (antibiotics) Anion-exchange binding resin (Cholestyramine) – binds cytotoxin of C.difficile – do not use together with vancomycin Repopulation of gut flora – ingestion of yeast Saccharomyces boulardii (in relapses) NB: Antidiarrheal agent SHOULD BE AVOIDED because it will prolong mucosal exposure to toxin and this also applies to post-op narcotic anaelgesia
  9. 9. Indicated for patients who are complicated with toxic megacolon with existing or subsequent risk of perforation Frequency is low (0.39 – 3.6%) Diverting ileostomy or subtotal colectomy Colostomy/ileostomy- for direct instillation of antibiotics into the colon lumen in patients with ileus (rare) Early subtotal colectomy- in fulminant toxic cases that do not respond to treatment after 7 days due to increased risk of perforation Overall mortality rate for patients requiring surgery is 30-35%
  10. 10. Not required however return of diarrhea may indicate the need for retreatment 10-20% of patients will have a relapse If properly treated, it is a self-limiting disease with good prognosis Overall mortality rate is 2% Mortality rate in untreated elderly or debilitated patients = 10-20% Mortality rate in patients with toxic megacolon = 35%
  11. 11. 1. Pseudomembranous colitis: Surgical Perspective http://www.emedicine.com/med/topic 2743.htm 2. Harrison’s Principles of Internal Medicine 14th Edition. McGraw-Hill Companies Inc.1998 3 Rang HP, Dale MM, Ritter JM. Pharmacology 3rd Edition. Churchill Livingstone.1995