Clostridium

Vancomicina o metronidazol para el tratamiento de la infección por Clostridium difficile: análisis clínicos y económicos

Perras C, E Tsakonas, S Ndegwa, J Conly, L Valiquette, Farrah K

Estado del registro

Se trata de un registro bibliográfico de una evaluación de tecnologías sanitarias publicados de un miembro de la INAHTA. No hay evaluación de la calidad de esta evaluación se ha realizado para la base de datos de HTA.

Detalles bibliográficos

Perras C, E Tsakonas, S Ndegwa, J Conly, L Valiquette, Farrah K. vancomicina o metronidazol para el tratamiento de la infección por Clostridium difficile: análisis clínicos y económicos. Ottawa: Agencia Canadiense de Medicamentos y Tecnologías en Salud (CADTH). Tecnología informe, no. 1362011

Objetivos de los autores

Los objetivos de la investigación fue evaluar la efectividad clínica relativa, la relación costo-efectividad y el impacto presupuestario del uso de la vancomicina o metronidazol en el tratamiento de los episodios iniciales de moderada a severa infección por C. difficile en niños o en adultos. Guías de práctica clínica las recomendaciones también fueron revisadas.

Conclusiones de los autores

Cinco ensayos controlados aleatorios incluían pacientes adultos hospitalizados con episodios iniciales o recurrentes de la infección por C. difficile. Con base en la información limitada que se obtuvieron de los análisis de subgrupos, el uso de metronidazol y vancomicina conduce a una tasa de curación clínica similar entre los pacientes adultos hospitalizados con infección difficile inicial o recurrente C. de gravedad moderada. Una mayor tasa de curación clínica se informó después de que el uso de la vancomicina en pacientes adultos hospitalizados con inicial o recurrente infección grave por C. difficile.Conclusiones sobre los resultados de las recurrencias, complicaciones y efectos adversos graves no se puede hacer.

El uso de vancomicina oral por los pacientes con enfermedad grave incurrirá en un costo adicional de 1,161 dólar por la curación clínica, pero el uso de la vancomicina puede reducir el gasto en salud neto, si que tiene un impacto en los costos de hospitalización a través de una menor duración de la estancia debido a la alta precoz o la reducción de complicaciones graves.

Los costos anuales adicionales por el empleo de vancomicina como tratamiento de primera línea en pacientes hospitalizados con infección grave por C. difficile son, a nivel nacional, 734.826 dólares para los hospitales y 398.454 dólares para los presupuestos de las drogas de la comunidad.

URL del papel original

http://www.cadth.ca/media/pdf/H0499_Cdifficile_tr_e.pdf

Datos adicionales URL

http://www.cadth.ca/index.php/en/hta/reports-publications/search/publication/2775

Indexación de Estado

Indización asignados por CRD

MeSH

Clostridium difficile, infecciones por Clostridium, los seres humanos, metronidazol, vancomicina

Idioma de publicación

Inglés

Dirección para la correspondencia

Agencia Canadiense para Medicamentos y Tecnologías en Salud, 865 Carling Avenue, Suite 600, 5S8 K1S Ottawa, Ontario, Canadá Correo electrónico: htainfo@cadth.ca

AccessionNumber

32011000141

Base de datos de fecha de entrada

02/02/2011

Evaluación de Tecnologías Sanitarias (ETS)

producida por el Centro de Revisiones y Difusión

Copyright © 2011 Universidad de York

Clostridium difficile-associated disease:

New challenges

from an established pathogen

R E V I EW

■ A B S T R A C T

Clostridium difficile-associated disease (CDAD) can range

from uncomplicated diarrhea to sepsis and even death.

CDAD rates and severity are increasing, possibly due to

a new strain. Transmission of C difficile occurs primarily

in health care facilities via the fecal-oral route following

transient contamination of the hands of health care

workers and patients; contamination of the patient care

environment also plays an important role.

■ K E Y P O I N T S

A recently identified strain of C difficile that has caused

numerous outbreaks of clinically severe disease in North

America and Europe produces 16 times more toxin A and

23 times more toxin B than other strains.

Since nosocomial CDAD is almost always associated with

antimicrobial use, one should avoid unnecessary and

inappropriate antimicrobial therapy.

If a patient has CDAD, the clinician must vigilantly

monitor for disease progression and follow infection

control guidelines to prevent spread to other patients.

Important principles in treating CDAD include stopping

the offending antimicrobial agent if possible, giving

metronidazole or vancomycin orally for no less than 10

days, and following patients closely for any signs of

clinical progression during therapy.

LOSTRIDIUM DIFFICILE-ASSOCIATED DISEASE

(CDAD) is increasing in incidence and

severity and may be becoming more difficult to

treat. Recent reports of a more virulent and possibly more resistant strain of C difficile’s causing

epidemics in both the United States and

Canada have heightened clinicians’ awareness

of CDAD, emphasizing the importance of early

recognition and appropriate treatment.

In this article, we review the current state

of knowledge concerning the epidemiology,

pathogenesis, clinical presentation, diagnosis,

treatment, and prevention of CDAD.

■ CASE REPORT

A 37-year-old man presented to the emergency

department because of diffuse abdominal pain

and nonbloody diarrhea. One day earlier he

had been discharged from the hospital, where

he had received ceftriaxone and azithromycin

for 7 days for bronchitis. Within hours after

going home he passed numerous liquid brown

stools; by evening he had become disoriented

and an ambulance was called. When he

arrived, emergency personnel gave him naloxone for a possible drug overdose, although his

fiancé reported that he had taken only one dose

each of hydromorphone and lorazepam since

returning home (later confirmed by pill count).

His medical history included chronic

obstructive pulmonary disease, depression,

chronic back pain, and tobacco use. Medications

included a fentanyl patch 75 µg/hour every 3

days, gabapentin 600 mg three times a day,

hydromorphone 4 mg every 4 hours as needed,

C188 C L E V E L A N D C L I N I C J O U R N A L O F M E D I C I N E V O L U M E 7 3 • N U M B E R 2 F E B R U A R Y 2 0 0 6

lorazepam 1 mg three times a day, and prednisone in tapering doses. He had no known drug

allergies and did not use alcohol or illicit drugs.

Laboratory values: white blood cell count

100 × 109

/L, hematocrit 62.3%, sodium 125

mmol/L, potassium 6.6 mmol/L, CO2

13

mmol/L, and metabolic acidosis.

An abdominal radiographic series showed

no evidence of obstruction.

The patient was admitted to the intensive

care unit and received fluids and pharmacologic support for hypotension, and metronidazole (Flagyl) 500 mg intravenously. Results of

computed tomography of the abdomen were

consistent with toxic megacolon.

The patient underwent emergent

exploratory laparotomy, which revealed a

swollen, edematous colon with pseudomembranes; a subtotal colectomy and ileostomy

were performed. After surgery, he was given a

second dose of intravenous metronidazole plus

intravenous ciprofloxacin and vancomycin

per rectum. Three days after surgery, the

patient developed ventricular fibrillation that

did not respond to several resuscitation

attempts, and he died.

Discussion

Although no testing for C difficile was performed before the patient died, histopathologic findings in the resected colon and in the

patient’s rectum on autopsy were consistent

with pseudomembranous colitis, a condition

considered pathognomonic for C difficile (FIGURE 1). Moreover, an immunohistochemical

stain for Clostridium species demonstrated

numerous organisms within the pseudomembranes (FIGURE 2).

Factors contributing to CDAD and death

in this patient include his receiving antimicrobial agents and proton-pump inhibitors,

both of which are risk factors for CDAD.1–4

Additionally, he received narcotics, which

may be a risk factor for toxic megacolon owing

to their antiperistaltic effects.5,6

This tragic death of a young, otherwise

healthy man illustrates the serious potential

complications of CDAD and the importance

of preventing and controlling it.

Pseudomembranous colitis

is considered

pathognomonic

for C difficile

C D I F F I C I L E S U N E N S H I N E A N D Mc DON A L D

C d i f f i c i l e- a s s o c i a t e d d i s e a s e : R e s e c t e d c o l o n i c m u c o s a

FIGURE 1. Photomicrograph of a

hematoxylin and eosin stain of the case

patient’s colonic mucosa just on the edge

of the pseudomembranous

...