Pépin Jacques, Routhier Sophie, Gagnon Sandra, Brazeau Isabel
Department of Microbiology and Infectious Diseases, University of Sherbrooke, Quebec, Canada.
Clin Infect Dis. 2006 Mar 15;42(6):758-64. doi: 10.1086/501126. Epub 2006 Feb 7.
During an epidemic of Clostridium difficile-associated disease (CDAD) caused by a strain that is a hyper-producer of toxins A and B, the frequency of a first recurrence after metronidazole treatment of the initial episode doubled in 2003-2004, compared with 1991-2002.
To examine whether administration of metronidazole as treatment for a first recurrence of CDAD remained appropriate, we reviewed data for patients with CDAD diagnosed in a hospital in Quebec, Canada, during 1991-2005, who experienced a first recurrence. The frequency of a second recurrence within 60 days after the first one was measured using Kaplan-Meier analysis. Cox regression was used for multivariate analysis.
A total of 463 patients had a first recurrence of CDAD, of whom 154 (33.3%) experienced a second recurrence. Independent predictors of a second recurrence were age and duration of hospitalization after the first recurrence; this latter finding suggested that many such episodes were reinfections rather than relapses. Neither choice of treatment drug (metronidazole or vancomycin) nor use of the same drug for treatment of first recurrence, as had been used during the initial episode, was associated with increased risk of a second recurrence. However, 51 patients (11.0%) developed at least 1 complication (i.e., shock, need for colectomy, megacolon, perforation, or death within 30 days) during the first recurrence. Older age, a high leukocyte count, and renal failure at first recurrence were strongly associated with a complicated CDAD.
Metronidazole is not inferior to vancomycin for treatment of patients with a first recurrence of CDAD, but the risk of complications with any treatment of CDAD may be higher than has previously been documented.
在由一种高毒素A和毒素B产生菌引起的艰难梭菌相关性疾病（CDAD）流行期间，与1991 - 2002年相比，2003 - 2004年甲硝唑治疗初始发作后首次复发的频率增加了一倍。
为了研究将甲硝唑用于治疗CDAD首次复发是否仍然合适，我们回顾了1991 - 2005年在加拿大魁北克一家医院诊断为CDAD且经历首次复发的患者的数据。使用Kaplan - Meier分析测量首次复发后60天内第二次复发的频率。Cox回归用于多变量分析。
共有463例患者首次复发CDAD，其中154例（33.3%）经历了第二次复发。第二次复发的独立预测因素是年龄和首次复发后的住院时间；后一项发现表明许多此类发作是再感染而非复发。治疗药物的选择（甲硝唑或万古霉素）以及在首次复发时使用与初始发作相同的药物进行治疗，均与第二次复发风险增加无关。然而，51例患者（11.0%）在首次复发期间出现了至少1种并发症（即休克、需要结肠切除术、巨结肠、穿孔或30天内死亡）。年龄较大、首次复发时白细胞计数高和肾衰竭与复杂性CDAD密切相关。
对于治疗CDAD首次复发的患者，甲硝唑并不逊于万古霉素，但CDAD任何治疗的并发症风险可能高于先前记录的水平。
