Should Metronidazole Be Recommended for Mild Clostridium difficile Infections?

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Clinicians debate whether metronidazole should be used as front-line treatment for mild CDI in patients with low risk for complications.
Clinicians debate whether metronidazole should be used as front-line treatment for mild CDI in patients with low risk for complications.

In a letter to the editors1 published in Clinical Infectious Diseases, the authors suggest that since the publication of the 2010 Clinical Practice Guidelines for Clostridium difficile Infection (CDI) in Adults and Children2 and a subsequent update published in 2017 by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America3 there is sufficient evidence to consider metronidazole as a first-line option for cases of mild CDI in low-risk patients. 

The investigators agreed with the latest guideline authors that “vancomycin should be first-line therapy for severe CDI based on robust clinical data,” but questioned why they excluded metronidazole as a treatment option for initial non-severe cases of CDI in adult patients.

The 2017 update includes data up to 2016 and is therefore missing a recent large multicenter propensity matched score study4 of >4,000 patients that showed no difference in recurrence or mortality between metronidazole and vancomycin in mild cases of CDI.

Further, they argue that if the 2017 update determinants of strength of recommendations, which include quality of evidence; patient's values and preferences; resources and cost; and balance between benefits, harm, and burdens are applied to metronidazole there is “high-quality evidence to support its use in mild CDI cases, lower cost compared to vancomycin, and less association with colonization/development of drug resistant organisms compared to vancomycin.”

The letter authors therefore recommended that metronidazole be considered as front-line treatment for mild CDI in patients with a low risk for complications.

References

    1. Fabre V, Dzintars K, Avdic E, Cosgrove SE. Role of metronidazole in mild Clostridium difficile infections [published online May 31 2018]. Clin Infect Dis. doi:10.1093/cid/ciy474

    2. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31:431-455.

    3. McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66:987-994.

    4. Stevens VW, Nelson RE, Schwab-Daugherty EM, et al. Comparative effectiveness of vancomycin and metronidazole for the prevention of recurrence and death in patients with Clostridium difficile infection. JAMA Intern Med. 2017;177:546-553.

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