A 2019 review provides updates on current guidelines for the treatment of Clostridium difficile infections (CDIs) and the role of vancomycin enemas in therapy, particularly for patients with ileus involvement (see Table 1). Generally, Data are retrieved from published case series, which detail the use of higher vancomycin dose, enema volume, and enema retention, with vancomycin doses typically distilled in 0.9% saline. Conversely, using lower doses (125-250 mg q6h) and volumes (e.g., 100 mL) did not result in significance when assessing clinical outcomes. Based on the evidence identified, the authors recommend using vancomycin 500 mg q6h, in a volume of 500 mL, per rectum via retention enema for patients with adynamic ileus for optimal efficacy. Notably, compounding instructions were not identified for the recommended vancomycin enemas. [1]
A 2020 narrative review summarized the evidence on the efficacy and adverse effects of high-dose vancomycin (> 500 mg/day) for the treatment of CDIs, which includes vancomycin retention enemas. Overall, key findings revealed little evidence supporting the superior efficacy of high-dose oral vancomycin over the standard 125 mg dose for non-severe or severe cases. In fulminant CDI, some weak observational evidence suggested potential benefits of high-dose oral vancomycin when combined with intravenous (IV) metronidazole and retention enemas, particularly in cases of ileus, though robust RCT data is lacking. It also highlighted the variable recommendations by major guidelines such as the Infectious Diseases Society of America (IDSA) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). These guidelines generally support the use of high-dose oral vancomycin in fulminant disease, particularly when ileus or toxic megacolon is present, with or without the addition of vancomycin retention enemas, while evidence remains insufficient for the routine use of high doses in non-fulminant CDI. In conclusion, larger studies are needed to clarify the role of high-dose vancomycin, particularly in fulminant CDI, and emphasize the need for better-defined dosing schedules to optimize treatment outcomes. [2]
A 2015 case report discussed the treatment of a 33-year-old man with refractory CDI resistant to vancomycin that ultimately required transplantation with fecal microbiota. In the case report, the authors prepared the vancomycin enema by instilling 500 mg of vancomycin in 100 mL of normal saline and administering 4 times per day. However, the patient returned 8 days later with complaints of pain and persistent diarrhea, necessitating the use of fecal microbiota, which eventually led to symptom resolution. [3]
A 2014 letter to the editor summarized the author’s institutional experience with the use of per rectum (PR) vancomycin in the treatment of CDI. The management guidelines for CDI recommend stratifying treatment based on disease severity, with the presence of ileus, megacolon, and hypotension/shock considered severe-complicated CDI. In these cases, guidelines suggest adding PR vancomycin to the standard treatment of oral vancomycin and IV metronidazole. The authors identified 17 patients who received PR vancomycin between 2005 and 2012, with the majority having severe-complicated CDI. The most common dosing regimen was 500 mg of PR vancomycin every 6 hours, and most patients (88%) also received concomitant oral vancomycin. However, there was a wide variety of vancomycin doses administered. The authors also observed a high failure rate (29%) among these patients, with three requiring colectomy, one receiving fecal transplantation, and one dying of CDI. [4]