Cure was defined as resolution of diarrhea by day six of therapy and negative C. difficile toxin A assays on days six and 10 of therapy. Results were statistically similar in both treatment groups with mild disease (98% vancomycin versus 90% metronidazole), but favored vancomycin in severe disease (97% versus 76%).
Relapse were not statistically different in either group (7% versus 14%). An albumin level less than 2.5 mg/dL or the presence of colonoscopy-confirmed pseudomembranous colitis showed statistically significant correlation with metronidazole treatment failure (relative risks of 12.70 and 6.67, respectively).
Bottom line: Oral vancomycin, with its commensurate potential for inducing vancomycin-resistant Enterococcus, proved to be equally effective as metronidazole in treating mild CDAD. It was statistically superior to metronidazole in severe disease with hypoalbuminemia and pseudomembranous colitis predicting failure of metronidazole therapy.
Citation: Zar FA, Bakkanagari SR, Moorthi KM, et al. A comparison of vancomycin and metronidazole for the treatment of C. difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45(3):302-307.
What Risk Factors Affect VTE Development in Outpatients?
Background: Decreasing lengths of stay have raised concern that treatments that previously would have continued during the longer hospital stays in the past, such as deep vein thrombosis prophylaxis, may result in unintended adverse consequences after discharge.
Study design: Retrospective observational study
Setting: Worcester, Mass., in 1999, 2001, and 2003, comprising residents who had diagnosis of venous thromboembolism (VTE) at any one of the 12 hospitals in the region
Synopsis: VTE was diagnosed in 1,897 residents (71.1%, 15.0% had pulmonary embolism [PE], and 13.9% had both). Further, 73.7% of the patients presented as an outpatient or were diagnosed within one day of hospital admission.
Compared with inpatients with VTE, outpatients were younger (63.3 years versus 67.4), were less likely to have had a recent infection (18.6% versus 46.8%), central venous catheter (10.4% versus 41.0%), recent fracture (7.3% versus 18.7%), heart failure (4.2% versus 16.5%), cardiac procedures (2.9% versus 7.8%), or recent intensive care unit care stay (8.7% versus 38.2%), but were more likely to have had a prior episode of VTE (19.9% versus 10.2%) or to be taking hormonal therapy (8.0% versus 3.0%).
The prevalence of malignancy was similar in both groups (29.0% versus 32.3%). Most outpatients diagnosed with VTE (59.9%) had been hospitalized in the preceding three months with a majority of VTEs diagnosed within 30 days of discharge. Only 59.7% of those previously hospitalized had any DVT prophylaxis (42.8% received anticoagulants, 16.9% had mechanical prophylaxis).
Bottom line: In an era of decreasing lengths of stay, the possible high level of outpatient VTE attributable to recent hospitalization may be at least partially due to inadequate inpatient pharmacologic VTE prophylaxis in more than 50% of the patients.
Citation: Spencer FA, Lessard D, Emery C, et al. Venous thromboembolism in the outpatient setting. Arch Intern Med. 2007;167(14):1471-1475.
How Has C. difficile Colitis Changed in Severity and Prevalence?
Background: Recent epidemic strains of Clostridium difficile have been reported with several studies suggesting that C. difficile infection has become more serious with risks for sepsis, colectomy, and death.
Study design: Cohort analysis of nationwide inpatient sample (NIS) discharge data for 11 years.
Synopsis: Of the more than 78 million discharge abstracts available for analysis, 299,453 patients were discharged with either a principle or secondary diagnosis of Clostridium difficile colitis (CDC). Demographics trends comparing the early period (1993-1996) versus the middle period (1997-2000) versus the late period (2001-2003) showed CDC incidence:
- Increased in older groups (65.6 years, 66.9 years, 67.6 years);
- Decreased in females (59.8%, 59.1%, 58.9%); and
- Decreased in Caucasians (70.90%, 67.20%, 59.10%).