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Although limited prospective randomized clinical trials showed no statistical differences among treatment agents for cessation of diarrhea (the primary outcome endpoint; Table 123-2), later observational studies suggest that response rates to metronidazole may have decreased. The clinical response rate for bacitracin is 10–20% lower than that for vancomycin; therefore, bacitracin use for first-line therapy is discouraged. All drugs, particularly vancomycin, should be given orally if possible. When IV metronidazole is administered, fecal bactericidal drug concentrations are achieved during acute diarrhea, and CDAD treatment has been successful; however, in the presence of adynamic ileus, IV metronidazole treatment of PMC has. | Chapter 123. Clostridium difficile-Associated Disease Including Pseudomembranous Colitis Part 4 Although limited prospective randomized clinical trials showed no statistical differences among treatment agents for cessation of diarrhea the primary outcome endpoint Table 123-2 later observational studies suggest that response rates to metronidazole may have decreased. The clinical response rate for bacitracin is 10-20 lower than that for vancomycin therefore bacitracin use for first-line therapy is discouraged. All drugs particularly vancomycin should be given orally if possible. When IV metronidazole is administered fecal bactericidal drug concentrations are achieved during acute diarrhea and CDAD treatment has been successful however in the presence of adynamic ileus IV metronidazole treatment of PMC has failed. In previous randomized trials diarrhea response rates to oral therapy with vancomycin or metronidazole were 94 but two recent observational studies found that metronidazole response rates had declined to 74 and 78 . Although the mean time to resolution of diarrhea is 2-4 days the response to metronidazole may be much slower. Treatment should not be deemed a failure until a drug has been given for at least 6 days. On the basis of data for shorter courses of vancomycin Table 123-2 it is recommended that metronidazole and vancomycin be given for at least 10 days although no controlled comparisons are available. Although metronidazole is not approved for this indication by the U.S. Food and Drug Administration FDA most patients with mild to moderate illness respond to 500 mg given by mouth three times a day for 10 days extension of the treatment period may be needed for slow responders. Because of the recent increase in metronidazole failures patients treated with this drug should be monitored carefully for progressive defervescence if fever is present alleviation of abdominal pain and tenderness decreases in the number of daily bowel movements and decreases in
