Does the presence of an ostomy reduce the effectiveness of vancomycin for Clostridioides difficile (C. difficile) colitis?

Effectiveness of Vancomycin for C. difficile Colitis in Patients with Ostomies

Trans-stoma vancomycin administration is effective for treating C. difficile colitis in patients with ostomies, and may be a necessary route of administration when oral delivery is compromised. 1

Pharmacokinetics and Delivery Considerations

• Oral vancomycin is poorly absorbed from the gastrointestinal tract in patients with normal intestinal mucosa, which is why it's effective for treating C. difficile infection (CDI) while minimizing systemic effects 2
• In patients with ostomies, the standard oral route of administration may be compromised due to altered gastrointestinal anatomy 1
• Trans-stoma vancomycin administration can be effective in surgical patients with Hartmann resection, ileostomy, or colon diversion 1

Evidence for Trans-stoma Administration

• The 2019 World Society of Emergency Surgery (WSES) guidelines specifically mention that trans-stoma vancomycin may be effective in surgical patients with ostomies 1
• In patients with severe C. difficile colitis who have undergone diverting loop ileostomy, postoperative antegrade instillation of vancomycin flushes via the ileostomy has been shown to be effective 1
• A prospective study of 42 patients with fulminant C. difficile colitis managed by loop ileostomy and postoperative antegrade vancomycin flushes demonstrated reduced mortality compared to historical controls 1
• Preservation of the colon was achieved in 93% of these patients, with vancomycin antegrade enemas continued via the ileostomy every 6 hours for 10 days 1

Dosing Considerations

• Standard oral vancomycin dosing for C. difficile colitis is 125 mg four times daily for 10 days 1
• For severe or fulminant C. difficile infection, higher doses (up to 500 mg four times daily) may be considered 1, 2
• When administering vancomycin via an ostomy, similar dosing regimens can be used 1
• A comparative study of two vancomycin dosage regimens (125 mg vs 500 mg four times daily) showed no significant differences in measurable responses, suggesting the lower dose is adequate unless the patient is critically ill 3

Special Considerations for Patients with Ostomies

• In patients with colostomies, vancomycin can be administered directly through the stoma 4
• A case report demonstrated dramatic clinical improvement in a patient with toxic megacolon associated with fulminant pseudomembranous colitis who underwent transverse colostomy and received postoperative vancomycin both orally and by administration from the stoma 4
• For patients with ileostomies, continuous enteral vancomycin infusion via a postpyloric feeding tube has been shown to be effective in critically ill patients 5
• A study of 11 patients receiving continuous enteral vancomycin infusion showed clinical improvement in 63% of patients with severe CDI who were at high surgical risk 5

Management Algorithm for C. difficile Colitis in Patients with Ostomies

1. For patients with mild to moderate C. difficile colitis and an ostomy:

   • Administer vancomycin 125 mg four times daily via the ostomy for 10 days 1, 3

2. For patients with severe C. difficile colitis and an ostomy:

   • Consider increasing the dose to 500 mg four times daily via the ostomy 1, 2
   • Monitor for signs of worsening infection, including increasing leukocytosis, fever, and abdominal pain 1

3. For patients with fulminant C. difficile colitis and an ostomy:

   • Administer vancomycin 500 mg four times daily via the ostomy plus intravenous metronidazole 500 mg three times daily 1
   • Consider adding vancomycin retention enemas if rectal stump is present 1
   • Early surgical evaluation should be provided 1

Potential Pitfalls and Caveats

• Ensure proper placement and patency of the ostomy before administering medications 2
• Be aware that patients with multiple recurrences of C. difficile infection may require alternative approaches, such as fidaxomicin or fecal microbiota transplantation 6
• Monitor for signs of systemic absorption of vancomycin in patients with renal failure or significant bowel inflammation 2
• In patients with severe abdominal distention suggesting megacolon or perforation, early surgical evaluation is essential 2