Intravenous metronidazole for the treatment of Clostridium difficile colitis

PURPOSE: Severe Clostridium difficile colitis may produce abdominal distent ion and ileus, precluding oral antibiotic therapy. Stimulated by several ca se reports in which intravenous metronidazole was used, we reviewed our exp erience. METHODS: Using pharmacy and microbiology laboratory records, we re trospectively identified patients with C. difficile colitis who received in travenous metronidazole as initial monotherapy. To be included, patients ha d to fulfill the following criteria: 1) at least six doses (equivalent to t wo days of therapy) of intravenous metronidazole were administered, 2) no o ther potential cause for colitis was found, and 3) the diagnosis of C. diff icile colitis was firmly established. For eligible patients, five clinical parameters were assessed before and after intravenous metronidazole. RESULT S: Our patient group (n = 10) received an average of 13.7 (range, 6-24) dos es of intravenous metronidazole as initial therapy for C. difficile colitis . All received a dose of 500 mg three times daily. The majority of patients with vomiting, fever, and/or abdominal pain present at the beginning of th erapy had resolution with intravenous metronidazole. Only one patient devel oped a symptom (vomiting) while on therapy; however, this eventually resolv ed when oral metronidazole was instituted. No patient required colectomy fo r refractory colitis or developed toxic megacolon. No patient, including th ose on prolonged courses, developed toxicity related to intravenous metroni dazole such as peripheral neuropathy. CONCLUSIONS: Intravenous metronidazol e may be effective therapy in patients with C. difficile colitis. A randomi zed, prospective study appears warranted.