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C. difficile mortality lower with vancomycin vs. metronidazole.

TREATING CLOSTRIDIUM difficile infection with vancomycin achieves the same recurrence rates as does treatment with metronidazole, but with a significantly lower 30-day mortality, a study showed.

The retrospective, propensity-matched cohort study examined U.S. Department of Veterans Affairs health care system data from 47,471 patients with C. difficile infection who were treated with either van comycin or metronidazole.

"Current guidelines recommend metronidazole hydrochloride as initial therapy for most cases of mild to moderate CDI [Clostridium difficile infection]," wrote Vanessa W. Stevens, PhD, of the Veterans Affairs Salt Lake City Health Care System, and her coauthors. 'Although an early clinical trial found no difference in cure rates between vancomycin hydrochloride and metronidazole, subsequent observational data and clinical trials suggest that metronidazole is inferior to vancomycin for primary clinical cure, especially in severe cases."

Their study found patients treated with vancomycin had a similar risk of recurrence, compared with those treated with metronidazole (relative risk, 0.98; 95% confidence interval, 0.87-1.10), with an overall recurrence rate of 16%.

However, patients treated with vancomycin had a 14% reduction in 30-day mortality, compared with the metronidazole-treated group. This was after adjustment for factors such as comorbidity scores, hospitalization history, receipt of chemotherapy, receipt of immunosuppressive medication or proton pump inhibitor therapy in the prior 30 days, or antibiotic use on the day of diagnosis.

The 30-day mortality was not significantly different among patients with mild to moderate CDI, but there was a significant 21% reduction among patients with severe infection. The number needed to treat to prevent one death among patients with severe infection was 25 (JAMA Intern Med. 2017 Feb 6. doi: 10.1001/ jamainternmed.2016.9045).

"This is the largest study to date to compare vancomycin and metronidazole in a real-world setting and one of the few studies focused on downstream outcomes of CDI," they reported.

The authors noted that despite strong evidence and guidelines supporting the use of vancomycin for severe CDI--and the fact that 42% of episodes in the study were classified as severe--only 4%-6% of patients were prescribed vancomycin.

"One approach to minimizing the effects of increasing vancomycin use is to target vancomycin treatment to patients with severe disease," they wrote.

The study was supported by research grants from the U.S. Department of Veterans Affairs. No conflicts of interest were declared.

imnews@frontlinemedcom.com

BY BIANCA NOGRADY

FROM JAMA INTERNAL MEDICINE

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Title Annotation:INFECTIOUS DISEASES
Author:Nogrady, Bianca
Publication:Internal Medicine News
Date:Mar 1, 2017
Words:397
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