Abigail Zuger, MD reviewing Stevens VW et al. JAMA Intern Med 2017 Feb 06.

These drugs are equivalent for mild-to-moderate disease, but vancomycin is superior for severe disease.

Both oral vancomycin and oral metronidazole are effective treatments for patients with Clostridium difficile infection (CDI). Although neither drug has clearly been superior in head-to-head comparisons, some clinicians feel that vancomycin is the “stronger drug.” However, because of vancomycin's expense and the ever-present worry about drug resistance, current guidelines recommend reserving vancomycin for patients with severe disease. Does this policy make sense? Researchers reviewed a large Veterans Affairs database and identified 2068 CDI patients (median age, 70; 95% men) who were treated with oral vancomycin as first-line therapy between 2005 and 2012; these patients were matched by a range of comorbidities with 8069 CDI patients who received oral metronidazole. In 3130 patients, CDI met standard criteria for severe disease as defined by the presence of leukocytosis and acute renal failure.

Among patients with severe disease, 30-day all-cause mortality was significantly lower for those who were treated with oral vancomycin than for those who were treated with metronidazole (15% vs. 20%); 30-day mortality did not differ significantly among patients with mild-to-moderate disease. Also, CDI relapse rates did not differ between treatment groups in either stratum of disease severity.

CITATION(S):

Stevens VW et al. Comparative effectiveness of vancomycin and metronidazole for the prevention of recurrence and death in patients with Clostridium difficile infection. JAMA Intern Med 2017 Feb 06; [e-pub].

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