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A retrospective review of metronidazole and vancomycin in the management of Clostridium difficile infection in patients with hematologic malignancies.
J Oncol Pharm Pract. 2014 Jun; 20(3):172-82.JO

Abstract

BACKGROUND

The incidence and severity of Clostridium difficile infection has significantly increased over the past decade. Although the epidemiology and treatment of C. difficile infection is well elucidated in the non-oncology population, it is poorly understood among cancer patients. This illustrates great concern as the majority of these patients are immunosuppressed, which puts them at higher risk for developing severe disease. Furthermore, suboptimal treatment of C. difficile infection can compromise care of underlying malignancy. Due to limited amount of data, we conducted this study to better ascertain the epidemiology and treatment outcomes of C. difficile infection in a subset of oncology patients at our institution.

OBJECTIVES

The primary objective was to assess the incidence and severity of C. difficile infection in patients with hematologic malignancies, including those undergoing hematopoietic stem cell transplant for a hematologic condition. The secondary objectives were to assess: (a) the outcome of C. difficile infection after therapy with metronidazole and/or vancomycin and (b) mortality following C. difficile infection.

METHODS

We performed a retrospective study to assess the incidence and severity of C. difficile infection and to evaluate outcomes of therapy with metronidazole and/or vancomycin among adult patients admitted to the Malignant Hematology/Blood and Marrow Transplantation service at our center from January 2009 to 2012.

RESULTS

Of the 390 admitted patients during the 3-year study period, the overall incidence of C. difficile infection was 18.7% (n = 73). Forty-six patients (63.0%) were deemed to have mild-moderate C. difficile infection. With regards to outcome of therapy, less exposure to antimicrobial agents was significantly associated with a higher resolution rate (p = 0.0029). Response rates to metronidazole were 53.7%, vancomycin 50%, and combination therapy 38.5%, although no difference in achievement of resolution was found among the three treatment modalities (p = 0.5533). Older patients were more likely to experience recurrent C. difficile infection (p = 0.0007). It was found that 55 patients (75.3%) were alive at 6 months.

CONCLUSIONS

These results highlight the high incidence of C. difficile infection in a subset of cancer patients at our institution. Although most patients presented with mild-moderate disease, severity of C. difficile infection in cancer patients may be underestimated due to the frequent presence of neutropenia. This study is the first analysis conducted, which directly compares outcomes of C. difficile infection after therapy with metronidazole, vancomycin, or combination therapy exclusively in patients with hematologic malignancies, including those undergoing hematopoietic stem cell transplant for a hematologic condition. We found no difference in treatment outcomes among metronidazole, vancomycin, or combination therapy. The recommendation from the literature to use metronidazole as the initial drug of choice for mild-moderate C. difficile infection is a reasonable option, although the rate of cure is low. This study highlights the critical need for better treatment options, due to suboptimal response rates to current therapy. Larger scale studies are needed to better understand the epidemiology and management of C. difficile infection in this patient population.

Authors+Show Affiliations

Department of Pharmacy, Stony Brook University Hospital, Stony Brook, NY, USA.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

23804627

Citation

Parmar, Sapna R., et al. "A Retrospective Review of Metronidazole and Vancomycin in the Management of Clostridium Difficile Infection in Patients With Hematologic Malignancies." Journal of Oncology Pharmacy Practice : Official Publication of the International Society of Oncology Pharmacy Practitioners, vol. 20, no. 3, 2014, pp. 172-82.
Parmar SR, Bhatt V, Yang J, et al. A retrospective review of metronidazole and vancomycin in the management of Clostridium difficile infection in patients with hematologic malignancies. J Oncol Pharm Pract. 2014;20(3):172-82.
Parmar, S. R., Bhatt, V., Yang, J., Zhang, Q., & Schuster, M. (2014). A retrospective review of metronidazole and vancomycin in the management of Clostridium difficile infection in patients with hematologic malignancies. Journal of Oncology Pharmacy Practice : Official Publication of the International Society of Oncology Pharmacy Practitioners, 20(3), 172-82. https://doi.org/10.1177/1078155213490004
Parmar SR, et al. A Retrospective Review of Metronidazole and Vancomycin in the Management of Clostridium Difficile Infection in Patients With Hematologic Malignancies. J Oncol Pharm Pract. 2014;20(3):172-82. PubMed PMID: 23804627.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - A retrospective review of metronidazole and vancomycin in the management of Clostridium difficile infection in patients with hematologic malignancies. AU - Parmar,Sapna R, AU - Bhatt,Valkal, AU - Yang,Jie, AU - Zhang,Qiao, AU - Schuster,Michael, Y1 - 2013/06/26/ PY - 2013/6/28/entrez PY - 2013/6/28/pubmed PY - 2014/12/23/medline KW - Clostridium difficile infection KW - hematologic malignancy KW - metronidazole KW - vancomycin SP - 172 EP - 82 JF - Journal of oncology pharmacy practice : official publication of the International Society of Oncology Pharmacy Practitioners JO - J Oncol Pharm Pract VL - 20 IS - 3 N2 - BACKGROUND: The incidence and severity of Clostridium difficile infection has significantly increased over the past decade. Although the epidemiology and treatment of C. difficile infection is well elucidated in the non-oncology population, it is poorly understood among cancer patients. This illustrates great concern as the majority of these patients are immunosuppressed, which puts them at higher risk for developing severe disease. Furthermore, suboptimal treatment of C. difficile infection can compromise care of underlying malignancy. Due to limited amount of data, we conducted this study to better ascertain the epidemiology and treatment outcomes of C. difficile infection in a subset of oncology patients at our institution. OBJECTIVES: The primary objective was to assess the incidence and severity of C. difficile infection in patients with hematologic malignancies, including those undergoing hematopoietic stem cell transplant for a hematologic condition. The secondary objectives were to assess: (a) the outcome of C. difficile infection after therapy with metronidazole and/or vancomycin and (b) mortality following C. difficile infection. METHODS: We performed a retrospective study to assess the incidence and severity of C. difficile infection and to evaluate outcomes of therapy with metronidazole and/or vancomycin among adult patients admitted to the Malignant Hematology/Blood and Marrow Transplantation service at our center from January 2009 to 2012. RESULTS: Of the 390 admitted patients during the 3-year study period, the overall incidence of C. difficile infection was 18.7% (n = 73). Forty-six patients (63.0%) were deemed to have mild-moderate C. difficile infection. With regards to outcome of therapy, less exposure to antimicrobial agents was significantly associated with a higher resolution rate (p = 0.0029). Response rates to metronidazole were 53.7%, vancomycin 50%, and combination therapy 38.5%, although no difference in achievement of resolution was found among the three treatment modalities (p = 0.5533). Older patients were more likely to experience recurrent C. difficile infection (p = 0.0007). It was found that 55 patients (75.3%) were alive at 6 months. CONCLUSIONS: These results highlight the high incidence of C. difficile infection in a subset of cancer patients at our institution. Although most patients presented with mild-moderate disease, severity of C. difficile infection in cancer patients may be underestimated due to the frequent presence of neutropenia. This study is the first analysis conducted, which directly compares outcomes of C. difficile infection after therapy with metronidazole, vancomycin, or combination therapy exclusively in patients with hematologic malignancies, including those undergoing hematopoietic stem cell transplant for a hematologic condition. We found no difference in treatment outcomes among metronidazole, vancomycin, or combination therapy. The recommendation from the literature to use metronidazole as the initial drug of choice for mild-moderate C. difficile infection is a reasonable option, although the rate of cure is low. This study highlights the critical need for better treatment options, due to suboptimal response rates to current therapy. Larger scale studies are needed to better understand the epidemiology and management of C. difficile infection in this patient population. SN - 1477-092X UR - https://www.unboundmedicine.com/medline/citation/23804627/A_retrospective_review_of_metronidazole_and_vancomycin_in_the_management_of_Clostridium_difficile_infection_in_patients_with_hematologic_malignancies_ L2 - http://journals.sagepub.com/doi/full/10.1177/1078155213490004?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -