1404. The Addition of Intravenous Metronidazole to Oral Vancomycin Improves Mortality in Critically Ill Patients with Clostridium difficile Infection (CDI)
Session: Poster Abstract Session: Clostridium difficile
Saturday, October 5, 2013
Room: The Moscone Center: Poster Hall C
  • CDI IDWeek Poster FINAL.pdf (212.0 kB)
  • Background: Minimal data exist to support a preferred regimen in patients with Clostridium difficileinfection (CDI) requiring admission to the intensive care unit (ICU). This study aims to evaluate the difference in mortality among critically ill patients with CDI who received oral vancomycin (monotherapy) versus oral vancomycin with intravenous (IV) metronidazole (combination therapy).

    Methods: This was a single center, retrospective, observational, comparative study. The electronic medical records of critically ill patients with a positive C. difficile PCR or toxin assay admitted to the ICU from June 2007 to September 2012 were evaluated. To be considered critically ill, patients had to meet 3 of 7 criteria: albumin <2.5 g/dL, heart rate >90 bpm, mean arterial pressure <60 mmHg, WBC greater than or equal to 15,000 cells/mL, age >60 years, serum creatinine greater than or equal to 1.5 times baseline, or temperature greater than or equal to 100.4ºF. All patients received oral vancomycin in an ICU.  In the combination therapy group, patients received concurrent IV metronidazole within 48 hours of starting vancomycin. Patients <18 years or with unrelated gastrointestinal disease were excluded. The primary outcome was in-hospital mortality. Secondary outcomes included clinical success at day 6 (using pre-determined criteria), length of stay (LOS), and ICU LOS after CDI diagnosis.  Patients were matched based on Acute Physiology and Chronic Health Evaluation II (APACHE II) scores.



    Monotherapy (n=44)

    Combination (n=44)


    Patient characteristics

    Age, mean ± SD

    Female gender, n (%)

    APACHE II, mean ± SD

    Charlson Comorbidity Index, mean ± SD

    60.5 ± 15.3

    24 (54.5)

    26.4 ± 6.9

    5.2 ± 2.7

    60.9 ± 14.8

    28 (63.6)

    26.8 ± 6.9

    5.9 ± 2.4





    Primary outcome

    In-hospital mortality, n (%)

    16 (36.4)

    7 (15.9)


    Secondary outcomes

    Clinical success, n (%)

    LOS, median (range)

    ICU LOS after CDI, median (range)

    8 (18.1)

    32.0 (6-170)

    9.0 (4-60)

    5 (11.4)

    27.0 (7-223)

    11.0 (3-68)




    Conclusion: Critically ill patients with CDI should receive combination therapy with oral vancomycin and IV metronidazole.  Further studies defining optimal treatment regimens in critically ill patients with CDI are warranted.

    Kristina Rokas, PharmD1, James Johnson, PharmD1, James Beardsley, PharmD1, Christopher Ohl, MD2, Vera Luther, MD2 and John Williamson, PharmD1, (1)Wake Forest Baptist Health, Winston-Salem, NC, (2)IM-Section On Infectious Diseases, Wake Forest School of Medicine, Winston-Salem, NC


    K. Rokas, None

    J. Johnson, None

    J. Beardsley, None

    C. Ohl, None

    V. Luther, None

    J. Williamson, None

    Findings in the abstracts are embargoed until 12:01 a.m. PST, Oct. 2nd with the exception of research findings presented at the IDWeek press conferences.