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Z Gastroenterol 2020; 58(08): 778-784
DOI: 10.1055/a-1190-5735
Übersicht

Behandlung der leichten Clostridioides-difficile-Infektion – hat Metronidazol noch einen Stellenwert?

Non-severe Clostridioides difficile Infection: Are the data adequate to give up metronidazole?
Andreas Stallmach
  Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Deutschland
,
Katrin Katzer
  Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Deutschland
,
Philipp Reuken
  Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie und Infektiologie), Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Deutschland
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Zusammenfassung

Clostridioides-difficile-Infektionen (CDI) sind typische Komplikationen einer Antibiotikatherapie. Wenn auch die durch C. diff. verursachten Krankheitsbilder bis zum toxischen Megakolon mit letalen Verläufen reichen können, sind leichte Verlaufsformen mit unkomplizierter Diarrhoe bei Weitem am häufigsten. Auch die Behandlung dieser Krankheitsbilder sollte leitliniengerecht erfolgen. Die zurzeit gültigen internationalen Leitlinien sind bezüglich der Therapie der leichten Infektion mit Metronidazol aber widersprüchlich. Vor diesem Hintergrund erfolgte eine selektive Literaturrecherche zu Leitlinien und Behandlungsstudien zum Einsatz von Metronidazol bei leichter CDI. Die Auswertung randomisierter kontrollierter Studien zeigt eine statistische Überlegenheit von Vancomycin gegenüber Metronidazol (NNT 16). Unter Einbeziehung großer Kohortenstudien reduziert sich dieser Unterschied in der Effektivität auf 2,5 % (NNT 40). Inkonsistente Kriterien zur Definition einer leichten CDI, unterschiedliche Dosierungen, Applikationen und Zeitintervalle (z. B. zusätzliche Gabe von Metronidazol i. v.) sowie der retrospektive Charakter mancher Studien verhindern das Erkennen möglicher Einflüsse von Störgrößen bei dieser Bewertung. Dennoch kann eine leichte CDI erfolgreich mit Metronidazol behandelt werden; andere Empfehlungen insbesondere amerikanischer Gesellschaften sollten deshalb kritisch bewertet werden. Wichtig ist, dass diese Therapieempfehlung nicht für Patienten mit chronisch entzündlichen Darmerkrankungen oder andere Patienten mit relevanten Komorbiditäten gilt.

Abstract

Clostridioides difficile infections (CDI) are typical antibiotic therapy associated complications. Notwithstanding the fact that the clinical picture of CDI may extend to the development of a toxic megacolon with potentially life-threatening sequelae, mild infectious forms associated with uncomplicated diarrhoea are by far the most prevalent and should also be treated according to clear clinical practice guidelines. However, there are currently conflicting international guidelines governing metronidazole-based treatment of mild infections. In light of this shortcoming, we performed a selective literature search of guidelines and clinical studies relating to the use of metronidazole for mild CDIs. The evaluation of randomised controlled trials demonstrates that, in statistical terms, vancomycin is significantly superior to metronidazole (NNT 16). When large cohort studies are included, this difference in effectiveness is reduced to 2,5 % (NNT 40). Inconsistent criteria for defining a mild CDI, different doses, applications and time intervals (e. g. additional IV administration of metronidazole) and the retrospective nature of some studies make it difficult to identify the influence of possible interference variables in this evaluation. Nevertheless, a mild CDI can be successfully treated with metronidazole; other recommendations, particularly those of American associations, should be evaluated critically. It is important to note that this therapy recommendation does not apply to patients with chronic inflammatory bowel diseases or other patients with pertinent comorbidities.

Schlüsselwörter

Clostridioides difficile - Therapie - leichte Infektion - Metronidazol

Key words

clostridioides difficile - therapy - mild to moderate infection - metronidazole


Publication History

Received: 11 March 2020

Accepted: 22 May 2020

Article published online:
12 August 2020

© Georg Thieme Verlag KG
Stuttgart · New York

 

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