Correspondence

Intracolonic Vancomycin for Pseudomembranous Colitis

N Engl J Med 1993; 329:583August 19, 1993

Article

To the Editor:

We report the use of intracolonic vancomycin to treat antibiotic-associated pseudomembranous colitis in a patient with paralytic ileus.

An 80-year-old man underwent combined aortocoronary-bypass grafting, thromboendarterectomy of the left carotid artery, and insertion of a Y-shaped aortoiliac graft. The initial postoperative course was uneventful. Four days after surgery, a suspected lung infection was treated with parenteral imipenem and later with ceftazidime and ciprofloxacin. Nine days after surgery, abdominal discomfort, fever, and leukocytosis (42,600 cells per cubic millimeter) developed. This was followed by paralytic ileus and two episodes of voluminous bloody diarrhea. Pseudomembranous colitis was diagnosed by colonoscopy, by the demonstration of both Clostridium difficile and its toxin in stool specimens, and by microscopical examination of biopsy specimens. Pseudomembranes were found predominantly in the cecum and the ascending colon.

The antibiotics used previously were discontinued, and vancomycin (125 mg four times daily) was administered through a nasogastric tube. Nevertheless, progressive multiorgan failure developed, and there was endoscopic evidence of local progression of disease. Several days later, during colonoscopy, a soft 6-French pigtail catheter was placed in the colon. The tip was positioned in the cecum. Vancomycin was administered directly into the colon in an initial dose of 2000 mg, followed by a 100-mg dose every six hours combined with an additional 100 mg after every watery stool. This therapy continued for 14 days. The patient's general condition and the local and systemic manifestations of pseudomembranous colitis improved substantially; temperature and leukocyte counts returned to normal levels. Repeated endoscopic examinations and analyses of stools did not reveal pathologic findings. Subsequently, recurrent bilateral pneumothoraxes developed. The patient died on the 52nd postoperative day of sepsis and multiorgan failure related to the pulmonary problems. An autopsy showed neither macroscopic nor histologic changes related to pseudomembranous colitis.

Oral administration of vancomycin is the method of choice for treating antibiotic-associated pseudomembranous colitis1. This therapy is unsuccessful in patients with paralytic ileus; because of their poor intestinal motility, an adequate intracolonic vancomycin concentration cannot be achieved2. Other alternatives include parenteral vancomycin therapy,3 the administration of vancomycin by enema or rectal lavage, colostomy or ileostomy for direct instillation of medication,4 and partial colectomy to remove the septic focus5. Our experience with this patient suggests that the placement of an elastic pigtail catheter into the colon during diagnostic colonoscopy and the subsequent repeated local administration of vancomycin may be a simple and effective therapy for pseudomembranous colitis associated with paralytic ileus.

Miralem Pasic, M.D., Sc.D.
Res Jost, M.D.
Thierry Carrel, M.D.
Ludwig Von Segesser, M.D.
Marko Turina, M.D.
University Hospital Zurich, CH-8091 Zurich, Switzerland

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   Joyce A. Generali, Dennis J. Cada. (2011) Off-Label Drug Uses - Vancomycin (Rectal): <i>Clostridium difficile</i> Infection (Severe/Complicated). Hospital Pharmacy 46:5, 327-328
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   V. Masciullo, S. Mainenti, D. Lorusso, P. A. Margariti, G. Scambia. (2010) Lethal Clostridium difficile Colitis Associated with Paclitaxel and Carboplatin Chemotherapy in Ovarian Carcinoma: Case Report and Review of the Literature. Obstetrics and Gynecology International 2010, 1-3
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   Anucha Apisarnthanarak, Behzad Razavi, Linda M. Mundy. (2002) Adjunctive Intracolonic Vancomycin for Severe Clostridium difficile Colitis: Case Series and Review of the Literature. Clinical Infectious Diseases 35:6, 690-696
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   John E. Mazuski, Walter E. Longo. (2002) Clostridium difficile Colitis. Problems in General Surgery 19:1, 121-132
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    Lorraine Kyne, Richard J. Farrell, Ciarán P. Kelly. (2001) Clostridium difficile. Gastroenterology Clinics of North America 30:3, 753-777
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    Frank Friedenberg, Angel Fernandez, Vivek Kaul, Pardis Niami, Gary M. Levine. (2001) Intravenous metronidazole for the treatment of Clostridium difficile colitis. Diseases of the Colon & Rectum 44:8, 1176-1180
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    Judith L. Trudel, Marc Deschênes, Serge Mayrand, Alan N. Barkun. (1995) Toxic megacolon complicating pseudomembranous enterocolitis. Diseases of the Colon & Rectum 38:10, 1033-1038
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