A meta-analysis of metronidazole and vancomycin for the treatment of Clostridium difﬁcile infection, stratiﬁed by disease severity
Fonte: Braz J Infect Dis;19(4): 339-349, July-Aug. 2015. tab, ilus
The aim of this meta-analysis was to compare the efﬁcacy of metronidazole and vancomycin for the treatment of Clostridium difﬁcileinfection, especially to investigate which agent was superior for treating either mild or severe C. difﬁcileinfection. A meta-analysis of randomized controlled trials and cohort studies identiﬁed in Pubmed, Embase, and the Cochrane Library was conducted. Four randomized controlled trials and two cohort studies involving 1218 patients were included in this meta-analysis. Metronidazole was inferior to vancomycin for treating C. difﬁcileinfection in terms of both initial clinical cure rates (risk ratio, RR = 0.91, 95% conﬁdence interval, CI = 0.84-0.98, p= 0.02) and sustained cure rates (RR = 0.88, 95% CI = 0.82-0.96, p= 0.003). For mild C. difﬁcileinfection, the efﬁcacy of metronidazole and vancomycin resulted in similar clinical cure rates (RR = 0.94, 95% CI = 0.84-1.04, p= 0.21) and sustained cure rates (RR = 0.93, 95% CI = 0.83-1.05, p= 0.26). For severe C. difﬁcileinfection the efﬁcacy of vancomycin was superior to metronidazole in terms of clinical cure rates (RR = 0.81, 95% CI = 0.69-0.95, p= 0.009), whereas sustained cure rates were similar (RR = 0.86, 95% CI = 0.72-1.02, p= 0.08). Regarding microbiological cure metronidazole therapy was as effective as vancomycin therapy (RR = 0.88, 95% CI = 0.64-1.21, p= 0.43). Recurrence rates with metronidazole and vancomycin for both mild C. difﬁcileinfection (RR = 0.95, 95% CI = 0.56-1.60, p= 0.85) and severe C. difﬁcileinfection (RR = 1.27, 95% CI = 0.85-1.91, p= 0.25) were not different. Likewise, no difference in all-cause mortality was found as well (RR = 0.87, 95% CI = 0.56-1.35, p= 0.53). In conclusion, vancomycin provides improved initial clinical and sustained cure rates in patients with C. difﬁcileinfection compared with metronidazole, especially in patients with severe C. difﬁcileinfection. In view of these data, vancomycin may be considered ﬁrst line therapy for severe C. difﬁcileinfection.