Rifaximin in the Treatment of Recurrent C. Difficile
Rifaximin in the Treatment of Recurrent C. Difficile
BackgroundClostridium difficile can cause severe antibiotic-associated colitis. Conventional treatments with metronidazole and vancomycin improve symptoms, but after discontinuation of treatment, C. difficile infection (CDI) recurs in a number of patients. Rifaximin is a rifamycin-based non-systemic antibiotic that has effect against C. difficile.
Aim To assess the effectiveness of rifaximin in recurrent C. difficile infection.
Methods We retrospectively evaluated the records of 32 patients who were treated with rifaximin for recurrent C. difficile infection. The symptoms were evaluated 12 weeks after the start of treatment and patient records were followed up until 1 year after treatment.
Results The mean age of the patients was 55 years (median 64, range: 19–84 years). Before the initiation of rifaximin therapy, the patients had undergone, on the average, 4.4 (range: 2–12) antimicrobial courses for C. difficile infection. C. difficile strain typing was performed in 27 patients. Eight (30%) patients had a strain with a DNA profile compatible with the BI/NAP1/027 ribotype. Antibiotic susceptibilities were determined of isolates from 22 patients. Most isolates (68%) had very low MIC-values for rifampin (<0.002 μg/mL) and the highest MIC value was 3.0 μg/mL. Isolates with a DNA profile compatible with the BI/NAP1/027 ribotype had, on the average, higher MICs of rifampin. After 12 weeks 17 (53%) patients had no relapse. The MIC value of rifampin seemed to predict the response to rifaximin treatment.
Conclusions Rifaximin is a safe treatment for C. difficile infection. It has a reasonable effect in C. difficile infection and it can be considered as an optional treatment for recurrent C. difficile infection.
Antibiotic treatments disturb the normal faecal microbiota. This can result in a longstanding and treatment-resistant colitis caused by Clostridium difficile, especially in elderly patients. Current treatments of CDI with metronidazole and vancomycin improve symptoms, but after discontinuation of treatment, colitis recurs in a number of patients leading to repeated therapies. For these reasons, new treatment options have been developed for CDI including faecal microbiota transplantation and various forms of immunotherapy. Also, other antibiotics have been introduced for the treatment of CDI including rifaximin and fidaxomicin. Both of these are nonsystemic drugs effective against C. difficile and, like vancomycin, are practically not absorbed from the gut. Fidaxomycin is a relatively new drug and was approved for CDI by FDA in 2011. It has shown a better effect in preventing relapses than vancomycin in two randomized studies. Rifaximin was first introduced for the treatment of traveller's diarrhoea and because it is minimally absorbed, well tolerated, and efficacious, it remains as an option for the treatment of uncomplicated traveller's diarrhoea. Rifaximin has also been used to reduce the risk of hepatic encephalopathy in patients with advanced liver disease and even for Crohn's disease. Initially, case reports indicated that rifaximin had an effect against CDI. Since then, a randomized study showed that rifaximin given immediately after a standard treatment with metronidazole or vancomycin had a better effect than placebo. We have used rifaximin in selected cases since 2007. We now report our experience with rifaximin in 32 patients with recurrent CDI.
Abstract and Introduction
Abstract
BackgroundClostridium difficile can cause severe antibiotic-associated colitis. Conventional treatments with metronidazole and vancomycin improve symptoms, but after discontinuation of treatment, C. difficile infection (CDI) recurs in a number of patients. Rifaximin is a rifamycin-based non-systemic antibiotic that has effect against C. difficile.
Aim To assess the effectiveness of rifaximin in recurrent C. difficile infection.
Methods We retrospectively evaluated the records of 32 patients who were treated with rifaximin for recurrent C. difficile infection. The symptoms were evaluated 12 weeks after the start of treatment and patient records were followed up until 1 year after treatment.
Results The mean age of the patients was 55 years (median 64, range: 19–84 years). Before the initiation of rifaximin therapy, the patients had undergone, on the average, 4.4 (range: 2–12) antimicrobial courses for C. difficile infection. C. difficile strain typing was performed in 27 patients. Eight (30%) patients had a strain with a DNA profile compatible with the BI/NAP1/027 ribotype. Antibiotic susceptibilities were determined of isolates from 22 patients. Most isolates (68%) had very low MIC-values for rifampin (<0.002 μg/mL) and the highest MIC value was 3.0 μg/mL. Isolates with a DNA profile compatible with the BI/NAP1/027 ribotype had, on the average, higher MICs of rifampin. After 12 weeks 17 (53%) patients had no relapse. The MIC value of rifampin seemed to predict the response to rifaximin treatment.
Conclusions Rifaximin is a safe treatment for C. difficile infection. It has a reasonable effect in C. difficile infection and it can be considered as an optional treatment for recurrent C. difficile infection.
Introduction
Antibiotic treatments disturb the normal faecal microbiota. This can result in a longstanding and treatment-resistant colitis caused by Clostridium difficile, especially in elderly patients. Current treatments of CDI with metronidazole and vancomycin improve symptoms, but after discontinuation of treatment, colitis recurs in a number of patients leading to repeated therapies. For these reasons, new treatment options have been developed for CDI including faecal microbiota transplantation and various forms of immunotherapy. Also, other antibiotics have been introduced for the treatment of CDI including rifaximin and fidaxomicin. Both of these are nonsystemic drugs effective against C. difficile and, like vancomycin, are practically not absorbed from the gut. Fidaxomycin is a relatively new drug and was approved for CDI by FDA in 2011. It has shown a better effect in preventing relapses than vancomycin in two randomized studies. Rifaximin was first introduced for the treatment of traveller's diarrhoea and because it is minimally absorbed, well tolerated, and efficacious, it remains as an option for the treatment of uncomplicated traveller's diarrhoea. Rifaximin has also been used to reduce the risk of hepatic encephalopathy in patients with advanced liver disease and even for Crohn's disease. Initially, case reports indicated that rifaximin had an effect against CDI. Since then, a randomized study showed that rifaximin given immediately after a standard treatment with metronidazole or vancomycin had a better effect than placebo. We have used rifaximin in selected cases since 2007. We now report our experience with rifaximin in 32 patients with recurrent CDI.
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