Introduction Approximately 30% of patients with Clostridium difficile infection have recurrent disease, despite adequate treatment of the initial episode. Some patients with severe C difficile-associated disease (CDAD) fail to respond to standard treatment with oral vancomycin (125 mg three time a day). Intravenous immunoglobulin (IVIG) has been used in the management of these two groups of patients but no controlled trials have been reported and published clinical experience is mixed. We report our experience of the use of IVIG in these patients, including subsequent course of disease.
Methods Clinical information was collected prospectively and/or retrospectively (via review of case notes and hospital information system) in seven patients [median age 77 yrs (range 52–91 yrs), six female] with recurrent CDAD and five patients [62 (21–75) yrs, four female] with severe C difficile-associated colitis. IVIG was used at a dose of 400 mg/kg, rifaximin was given for 2 weeks (200 mg twice daily) and Saccharomyces boulardii for 4 weeks (125 mg four times a day).
Results Recurrent CDAD: median 5 (range 3–8) episodes of disease occurred over 9 (6–15) months. Two patients (4 and 7 episodes) were treated with courses of vancomycin and did not subsequently have a recurrence over the following 5 and 40 months (respectively). In addition to vancomycin courses, three patients received rifaximin (two also had S boulardii) and were free of recurrence over subsequent 15–27 months. One patient (8 episodes) failed to respond to the above treatment, but after IVIG, there has been no recurrence (20 months follow-up). By contrast, a patient with myeloma did not respond to three IVIG infusions. Severe CDAD: CT showed colitis in all, CRP—107 (58–366) mg/l, WBC—17.2 (4.8–39.7)×109/l. In addition to IVIG, all also had high dose oral vancomycin (500 mg four times a day) and intravenous metronidazole. Four (out of five) responded and were subsequently discharged and one had recurrence (responded to oral vancomycin). One patient, whose IVIG was delayed by 48 h after it was recommended, required a colectomy.
Conclusion (1) Some patients with multiple recurrences of CDAD may not require treatment in addition to courses of vancomycin but others may respond to IVIG. (2) There may be a role for IVIG in the management of patients with severe acute CDAD. (3) Our experience may facilitate identification of clinical characteristics to enable recruitment of suitable patients, with recurrent or severe CDAD, in multi-centre clinical trials of IVIG.
Competing interests None declared.
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