Intracolonic Vancomycin Through Laprascopic Appendicostomy for Treatment of Severe Clostridium difficile Colitis Does Not Get Systemic Absorption

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To the Editor:
We report a 52-year-old male who presented with severe abdominal pain and diarrhea because of Clostridium difficile. He met the criteria for severe C. difficile colitis1 (Admission to intensive care unit with vasopressor support, white blood cell count peaking at 33.5, doubling serum creatinine from baseline and low serum albumin). Computed tomography of the abdomen was showing pan-colonic circumferential wall thickening.
The patient was initially treated with intravenous metronidazole 500 mg every 8 hours, oral vancomycin 500 mg every 6 hours, and enemas with no improvement. Repeat computed tomography was not showing persistent diffuse colonic wall edema.
It was determined that patient would benefit from an operative intervention. He underwent laprascopic appendicostomy. Two ports were introduced through incisions made in the infraumbilical and suprapubic areas. A third incision was then made in the right lower quadrant after the appendix was secured. The tip was opened and the meso-appendix was trimmed, then a 12-Fench Foleys catheter was introduced all the way to the cecum.
Continuous vancomycin pump was initiated throughout the catheter at a dose of 100 mg/h. His symptoms had improved and his white blood cell count normalized by day 5. Eight days after starting this therapy, a random serum vancomycin level was checked, the level was 1.4 mcg/mL. This suggests that vancomycin given using this route is not associated with significant systemic absorption.
Fulminant C. difficile colitis accounts for 3%–5% of the disease. Feature of complicated disease include Toxic megacolon, perforation, and need for emergency colectomy. Although initial steps in treatment remain essential (fluid resuscitation, stopping inciting antibiotics if possible, and empiric treatment of C. difficile colitis), surgical management may still be necessary. The procedure of choice described in the literature is subtotal colectomy with end ileostomy. Emerging alternative options have been described such as diverting loop ileostomy and colonic lavage.2
The approach taken in our case, to our knowledge, has not been described in the literature. This novel approach seems safe and effective.

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