Management of inflammatory bowel disease with Clostridium difficile infection

Table 5 Case reports of corticosteroid initiation in Clostridium difficile infection

Reference (year of publication)	Patient data		Treatment regimen	Outcome
	Demographics	Clinical presentation
Cavagnaro et al[104] (2003)	5M	Bloody diarrhea (> 10 loose stools/d), tenesmus, abdominal tenderness, fever	Oral vancomycin (40 mg/kg per day divided in 6-hourly doses) and IV metronidazole (20 mg/kg per day divided in 8-hourly doses) × 14 d	Resolution of diarrhea within 24 h of steroid initiation
		WBC 19000 cells/mm3, albumin 21 g/L		Resolution of endoscopic changes at 6 wk
		Positive C. difficile toxin	IV methyldrnisolone (2 mg/kg per day in two divided doses) on day 14 × 3 d
		Pseudomembranous colitis on flexible sigmoidoscopy on day 14	Prednisone 2 mg/kg per day tapered over one month
Sykes et al[105] (2012)	54F	Moderate CDI that resolved with 10-d course antibiotics	Oral metronidazole × 10 d with resolution of symptoms (doses not specified)	Decreased stool frequency, normalization of vital signs, reduction in CRP to 132 within 48 h of steroid initiation
		Recurrent diarrhea and abdominal pain 10 d after completion of antibiotics with		Resolution of diarrhea, further reduction in CRP to 15 after 9 d of steroid therapy
		left colonic thickening on CT and positive C. difficile toxin	Oral vancomycin and metronidazole upon admission (doses not specified) × 4 d	Resolution of endosocopic changes at 1 mo
		Fever, tachycardia on day 4		Sustained clinical response at 5 mo
		with pseudomembranous colitis on flexible sigmoidoscopy	Oral vancomycin 125 mg every 6 h × 9 d
		CRP increased from 149 on admission to 236 on day 4	IV hydrocortisone 100 mg every 6 h × 9 d
			Prednisolone 30 mg daily with tapering regimen
	73F	Moderate-severe CDI that resolved with 10-d course antibiotics	Metronidazole 400 mg every 8 h × 10 d with resolution of symptoms	Resolution of diarrhea, normalization of vital signs, reduction in CRP to 7 within 48 h of steroid initiation
		Recurrent moderate CDI 1 wk after completion of antibiotics that resolved with another 10-d course of antibiotics		Complete clinical response at 14 d with no further relapses
		Recurrent CDI 10 d after completion of antibiotics with fever, tachycardia, increased CRP 87	Oral vancomycin 125 mg every 6 h × 10 d with resolution of symptoms
		Slow response to antibiotics with flexible sigmoidoscopy on day 8 with pseudomembranous colitis
			Oral vancomycin 125 mg every 6 h × 8 d with tapering regimen over 14 d
			Prednisolone 30 mg daily × 7 d followed by tapering regimen
	91F	Moderate CDI with persistent diarrhea despite courses of metronidazole and vancomycin	Oral metronidazole 400 mg every 8 h × 10 d without resolution of symptoms	Resolution of diarrhea and normalization of CRP within 72 h of steroid initiation
		CRP 11		No further relapses
		Flexible sigmoidoscopy with pseudomembranous colitis	Oral vancomycin 125 mg every 6 h for prolonged course without resolution of symptoms
			Prednisolone 30 mg daily × 14 d with continued vancomycin tapering regimen over 4 wk

CDI: Clostridium difficile infection; CRP: C-reactive protein.