Extended Treatment With Vancomycin for Clostridium Difficile Colitis
Extended Treatment With Vancomycin for Clostridium Difficile Colitis
BACKGROUND: Clostridium difficile-associated colitis is an infection of the large bowel,
 usually associated with previous use of antibiotics. The disease course may be complicated by
 fulminant disease requiring removal of the colon or by multiple recurrences requiring
 re-hospitalization. The incidence and severity of Clostridium difficile infection is rising,
 and it poses an increasing burden on the health system. For example, in one of our previous
 studies we found that 804 in-patients and 568 out-patients had a positive test for
 Clostridium difficile toxin at Beaumont Laboratories in 2003. The standard treatment is a 2
 week course of Vancomycin or Metronidazole. The clinical response to Metronidazole appears to
 be declining, and many practicing clinicians prefer Vancomycin as a first-line treatment. The
 recurrence rate after the treatment is similar for Vancomycin and Metronidazole and is
 usually in the range of 15-25%, although recent reports noted a recurrence rate up to 50%
 during outbreaks with a virulent strain. Recently, it has been suggested that a 2 week
 duration of treatment might not be adequate in clearing the infection.

 Our HYPOTHESIS is that a prolongation of Vancomycin treatment from 2 weeks to 4 weeks will
 lead to a decrease rate of recurrent Clostridium Difficile colitis.
METHODOLOGY: Patients with a first episode of Clostridium difficile colitis will be offered a
 prolonged course of Vancomycin. It will be disclosed that this is not the standard of care,
 but that a prolonged course might decrease the relapse rate. After the initial treatment with
 Vancomycin 125 mg four times daily, the patients will be randomly assigned to receive either
 2 weeks of Vancomycin 125 mg four times daily or 2 weeks of placebo. The placebo solution
 will be prepared by our pharmacy to match the color and taste of the Vancomycin solution. The
 initial 2 weeks of therapy for both groups will be dispensed at patients' pharmacy. Patients
 will be called back at the end of 2 weeks and the blinded-phase drugs will be dispensed by
 our pharmacy staff.

 We will ask permission for a follow-up phone call at the end of treatment (1 month) and at a
 3-month interval. The patients will be followed longitudinally for a 3-month period. At the
 end of the follow-up interval, a review of any new medical records of the patient will be
 made and the patient will be contacted by phone for further details.
Inclusion Criteria:

 -  First episode of Clostridium difficile colitis, defined by a positive toxin assay plus
 at least one of the following: diarrhea, toxic megacolon or leukocytosis.

 Exclusion Criteria:

 -  previous diagnosis of Clostridium difficile colitis

 -  concomitant use of oral Metronidazole, Rifampin, Rifaximin, Nitazoxanide, Sacharromyce
 boulardii or Lactobacillus spp.

 -  age less than 18 years-old

 -  pregnancy.