Introduction: Severe colitis from infections with Clostridium Difficile that fails to respond to standard therapy with oral vancomycin and intravenous metronidazole require surgical exploration and subtotal colectomy. Historical controls report a mortality rate > 50% for patients who require colectomy and may be associated with an increase in incidence of cases with C.Difficile that produce high toxin levels.

Background: We initiated a protocol in our inner city hospital where inpatients with severe C.Difficile colitis infection were treated with intracolonic vancomycin (500 mg in 500 cc normal saline via rectal tube every 6 hours) and aggressive monitoring for potential surgical resection. We hypothesized that adjunct therapy with intracolonic vancomycin would decrease mortality and the need for surgical colonic resection.

Methods: We retrospectively reviewed all 47 patients with C.Difficile-positive colitis treated with intracolonic vancomycin from January 2007 through October 2009 in a large inner city hospital. We analyzed the cohort for age, gender, comorbidities, history of recent hospitalizations or nursing home stay, previous history of infectious colitis, previous antibiotic use, APACHE II severity score, resolution of colitis, incidence of surgery, and mortality.

Results: The average age of patients was 65 years (range 22 to 97) and 62% were female. Ninety-two percent of patients had significant comorbidities, and more than half were nursing home residents. Seventy percent had received antibiotics previously and 74% had been hospitalized within the past year. Twenty-three percent of patients were recurrent episodes. All patients had high APACHE II severity scores (Mean 24, Range 14-47). After treatment with adjunct intracolonic vancomycin, thirty-three of 47 (70%) patients showed complete resolution, and 14 of 47 (30%) demonstrated incomplete resolution of their colitis. Ten of 47 patients (21%) treated with intracolonic vancomycin expired. Nine of 47 patients (19%) who received intracolonic vancomycin required surgery. Seven patients (78%) who underwent surgery survived and two patients (22%) expired. Of 38 patients treated with intracolonic vancomycin without surgery, eight expired (21%) and 30 survived (79%). There were no complications attributable to intracolonic vancomycin.
Figure. Outcome of patients with severe C.Difficile colitis treated with adjunct intracolonic vancomycin.

Conclusion: Intracolonic vancomycin should be considered an adjunct method to treat fulminant C.Difficile colitis that may decrease the need for colectomy and improve mortality when used in addition to standard therapy with oral vancomycin and intravenous metronidazole. Some patients may progress to needing subtotal colectomy, and careful monitoring by a surgical service is incumbent. Further studies are necessary to identify patients who would benefit from earlier combination therapy or surgery.