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Intracolonic administration of vancomycin for Clostridium difficile infection

Grimm, Madelene MS, RN, CNS, CWOCN; Rafael, Teofila MSN, RN, NPDS

doi: 10.1097/01.NURSE.0000446632.85961.5a
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Update your knowledge about this effective therapy and review best practice recommendations for treating this potentially deadly disease.

Madelene Grimm is a wound, ostomy, and continence nurse and Teofila Rafael is a nursing professional development specialist at NorthShore University HealthSystem in Evanston, Ill.

The authors have disclosed that they have no financial relationships related to this article.

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THE INCIDENCE OF Clostridium difficile infection (CDI) has increased in recent years and is considered the most common cause of diarrhea in hospitalized patients.1 Mortality and morbidity are high in hospitalized adult patients with CDI because of its life-threatening complications, which include dehydration, perforated colon, and electrolyte imbalance.

In the past, treatment of CDI distal to an ileus where oral medications couldn't reach the problem resulted in colectomy and ostomy surgeries. This infection can now be treated with vancomycin administered at the site of the infection. This article provides an overview of this treatment option for CDI and best practice recommendations for the administration of antibiotics into the colon.

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Defining CDI

C. difficile, a Gram-positive spore-forming anaerobic bacillus, was first described in 1935 and accounts for 20% to 30% of antibiotic-associated cases of diarrhea in the healthcare setting.1,2 The primary mode of transmission is the fecal-oral route.3

CDI is identified by watery diarrhea and either a positive stool culture or colonoscopic or histopathologic findings demonstrating pseudomembranous colitis.2-4 Signs and symptoms range from mild diarrhea to life-threatening colitis, lower abdominal pain, and systemic alterations such as fever, anorexia, nausea, and malaise. Fulminant colitis occurs in 1% to 3% of patients and is characterized by severe toxicity with high fever and diffuse abdominal pain and distension.4 Diarrhea is classified as either mild (intestinal output of 500 mL or less per day) or moderate (501 to 2,000 mL/day). Severe diarrhea is defined as greater than 10 bowel movements per day, white blood cell count greater than 20,000/mm3, or severe abdominal pain.2,5

A key risk factor for CDI is previous exposure to an antimicrobial, chemotherapeutic, or immunosuppressive agent.2 Clindamycin, cephalosporins, and fluoroquinolones are associated with the greatest risk.6 All antimicrobials have the potential to suppress normal flora colonization, providing an environment for toxigenic strains of C. difficile to proliferate.3

C. difficile colonizes the human intestinal tract after normal gut flora has been altered by antibiotic therapy.3,5 Additional risk factors for CDI include contact with healthcare workers, a stay in an ICU or a prolonged hospital stay, increasing age, immune system compromise, contact with infected patients, surgery, exposure to gastric acid suppressants, and low serum antitoxin A immunoglobulin levels.2,7

CDI not only impacts a patient's physical recovery but also has a negative emotional impact as the patient experiences an unexpected delay in recovery, extending the length of stay and increasing the financial burden of the hospitalization. Prolonged hospital stays for CDI range from 3.6 days to 10.7 days, resulting in hospital costs being twice as high for patients with CDI as for patients without CDI.2,5,8 In the United States, it's estimated that there are over 475,000 initial and recurrent cases of CDI with a total range of expenses between $1 billion to $1.6 billion.8 CDI can be especially severe in patients with inflammatory bowel disease.7

CDI is almost always limited to the colonic mucosa; enteritis is rare.9 There are several irritable bowel-specific factors that increase the risk for CDI, the most important being immune suppression, which contributes to a twofold increase in the incidence of CDI.4,5

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Treating CDI

First-line treatment for nonsevere CDI consists of oral administration of metronidazole or vancomycin. Upon confirmation of CDI, all nonessential antimicrobial agents should be discontinued. With the initiation of therapy, all stool softeners and laxatives (including docusate salts, senna, and bisacodyl), and antidiarrheal agents (including loperamide, diphenoxylate with atropine, and bismuth subsalicylate) also should be discontinued.3

Vancomycin is also a first-line drug of choice for an initial episode of severe CDI.5 Intracolonic vancomycin (ICV) administered by enema, #18 French urinary catheter, or fecal management system is effective for patients who can't tolerate the oral dose and who have megacolon or a complete ileus that prevents oral medications from reaching the colon distal to the ileus. I.V. vancomycin has no effect on C. difficile because it's not excreted into the colon.5

Fecal transplant is another option for treating CDI. Some patients with severe CDI may need surgical intervention, such as a subtotal colectomy (removal of the entire colon with ileostomy, without removal of the rectum) or a diverting loop ileostomy with colonic lavage.5

Patients with megacolon may be helped with colonoscopic decompression and placement of a tube in the right colon, which can be perfused with vancomycin solution. It's important to note that vancomycin can be absorbed through inflamed colonic mucosa and cause toxicity if it accumulates in patients with renal failure.5

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Administering ICV

ICV is often administered via a retention enema.10 As with all enemas, the solution needs to flow with gravity into the rectum through the natural curve of the sigmoid colon to improve retention of the solution.11 Adverse reactions from enemas include vasovagal responses, respiratory arrest, electrolyte imbalance, rectal bleeding, perforations, and death.10,11 The enema should be discontinued if there are difficulties such as pain, inability to insert the tip of the tube, or patient complaints during insertion of the tip or administration of the fluid.10

Administering an enema with the patient sitting on the toilet is unsafe because curved rectal tubing can abrade the rectal wall. Traditionally the patient is positioned in a left side-lying (Sims) position with the right knee flexed. After explaining to the patient the procedure and that some abdominal distension and cramping are normal, lubricate the rectal tube with a water-soluble jelly and insert it slowly and gently to prevent trauma to the rectal mucosa. Insert the enema administration tube approximately 3 to 4 in (7.5 to 10 cm) in adults. Instillation time varies depending on the volume administered.10 The length of time for fluid retention varies as prescribed by the healthcare provider. Encourage the patient to retain the solution for an hour or as long as possible.

ICV may also be delivered by urinary catheter or a fecal management system. A urinary catheter is used for patients with no rectal sphincter tone or when instilling the ICV into a colostomy. Rectal sphincter tone must be present for use of a fecal management system.12

When the medication is administered using a #18 French catheter with 30 mL balloon catheter, insert the lubricated catheter 6 to 8 in (15.2 to 20.3 cm) into the rectum. Inflate the balloon with 20 to 30 mL of saline until snug. Draw medication into a catheter tip syringe and instill the medication, avoiding vigorous or forceful administration. Clamp the catheter for 1 hour (dwell time) by using a clamp or a rubber band over the folded catheter. Deflate the balloon after dwell time is completed. Remove and discard the catheter.13 Optimal dosing and volume of ICV haven't been established.5

To use a fecal management system, place the system into the rectal vault and inflate the retention ring per the manufacturer's instructions.

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Safe administration

The increased prevalence of CDI requires an aggressive and innovative method of controlling and eradicating C. difficile. Effective administration of intracolonic medication is required to prevent complications and reduce the financial impact of CDI.

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13. Grimm M, Rafael T. Vancomycin: intracolonic medication administration for patients being treated for Clostridium difficile ileus receiving vancomycin per rectal or colostomy route. NorthShore University HealthSystem Nursing Guidelines. Accepted by the Nursing Clinical Practice Council, 2013.
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