What is the treatment for enterocolitis?

From the Guidelines

Treatment for enterocolitis should prioritize supportive care, including fluid and electrolyte replacement, and targeted interventions based on the underlying cause, with infliximab or vedolizumab considered for second-line immunosuppression in cases unresponsive to glucocorticoids, as recommended by the most recent guidelines 1. The management of enterocolitis involves a step-wise approach, starting with supportive care to address dehydration and electrolyte imbalances, which can be achieved through oral rehydration solutions or intravenous fluids if necessary.

• Initial management focuses on:
  • Fluid and electrolyte replacement
  • Dietary modifications, including temporary bowel rest followed by a gradual reintroduction of easily digestible foods
  • Avoidance of anti-diarrheal medications like loperamide, which can worsen certain types of infectious enterocolitis For cases associated with immune checkpoint inhibitors (ICIs), the approach may differ, with consideration of withholding ICI therapy and initiating glucocorticoids as first-line treatment, followed by infliximab or vedolizumab if there is an inadequate response, as suggested by recent clinical practice updates 1.
• Key considerations in the management of ICI-associated enterocolitis include:
  • Endoscopic evaluation to assess disease activity and guide treatment decisions
  • Use of the Mayo Clinic Endoscopic Scoring system to assess disease severity 1
  • Consideration of second-line immunosuppression with infliximab or vedolizumab in cases unresponsive to glucocorticoids
  • Monitoring for potential complications, such as colonic ulceration, which may require alternative treatment approaches The choice between infliximab and vedolizumab for second-line immunosuppression should be based on individual patient factors, including underlying malignancy, comorbidities, and risk of infection, as well as the potential impact on antitumor responses 1.
• Factors to consider when selecting between infliximab and vedolizumab include:
  • Underlying hematologic malignancies, for which infliximab may be contraindicated
  • Severe congestive heart failure, for which infliximab should be used with caution
  • Primary GI malignancies or tumors with GI metastases, for which vedolizumab may interfere with antitumor responses Overall, the treatment approach for enterocolitis should prioritize a personalized and step-wise approach, taking into account the underlying cause, disease severity, and individual patient factors, with the goal of minimizing morbidity, mortality, and improving quality of life, as supported by the most recent and highest-quality evidence 1.

From the FDA Drug Label

Vancomycin Hydrochloride Capsules are indicated for the treatment of C. difficile-associated diarrhea. Vancomycin Hydrochloride Capsules are also used for the treatment of enterocolitis caused by Staphylococcus aureus (including methicillin-resistant strains) in adult and pediatric patients less than 18 years of age Staphylococcal enterocolitis: Total daily dosage is 500 mg to 2 g administered orally in 3 or 4 divided doses for 7 to 10 days. For both C. difficile-associated diarrhea and staphylococcal enterocolitis, the usual daily dosage is 40 mg/kg in 3 or 4 divided doses for 7 to 10 days. The total daily dosage should not exceed 2 g

The treatment for enterocolitis is vancomycin administered orally. The recommended dosage for adults with staphylococcal enterocolitis is 500 mg to 2 g per day, divided into 3 or 4 doses, for 7 to 10 days. For pediatric patients, the usual daily dosage is 40 mg/kg, divided into 3 or 4 doses, for 7 to 10 days, with a maximum total daily dosage of 2 g 2.

From the Research

Treatment Options for Enterocolitis

• The treatment for enterocolitis, specifically Clostridioides difficile infection (CDI) in patients with inflammatory bowel disease (IBD), involves the use of antibiotics such as vancomycin and fidaxomicin 3, 4, 5, 6, 7.
• Vancomycin is recommended for the treatment of severe CDI, while fidaxomicin is also effective in treating CDI, especially in patients with IBD 4, 5, 6.
• A study found that patients with ulcerative colitis and nonsevere CDI had fewer readmissions and shorter lengths of stay when treated with a vancomycin-containing regimen compared to those treated with metronidazole 3.
• Fidaxomicin has been shown to be effective and safe in IBD patients with CDI, with a lower recurrence rate and higher sustained response rate compared to vancomycin 4, 5, 6.
• Long-duration oral vancomycin therapy (21-42 days) is associated with a lower rate of CDI recurrence compared to short-duration therapy (10-14 days) 7.

Comparison of Treatment Outcomes

• A study compared the effectiveness of fidaxomicin and vancomycin in treating CDI and found that fidaxomicin was associated with a 63% reduction in the risk of clinical failure, 30-day relapse, or CDI-related death compared to vancomycin 6.
• Another study found that fidaxomicin led to resolution of CDI in 60.6% of patients with IBD, with a recurrence rate of 30.0% at a median of 55 days 5.
• Vancomycin-containing regimens have been shown to be effective in reducing readmissions and lengths of stay in patients with UC and nonsevere CDI 3.

Considerations for Treatment

• The choice of antibiotic therapy for CDI in patients with IBD should be based on the severity of the infection, the patient's medical history, and the presence of other health conditions 3, 4, 5, 6, 7.
• Fecal microbiota transplantation may be an effective therapy for patients who do not respond to fidaxomicin or vancomycin 5.