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Pseudomembranous Colitis and Rifampicin

1981; Elsevier BV; Volume: 80; Issue: 6 Linguagem: Inglês

10.1378/chest.80.6.766

1931-3543

Th. Prigogine, C. Potoliege, A Burette, Th. Verbeet, J Schmerber,

Tuberculosis Research and Epidemiology

To the Editor:To our knowledge, only four cases of rifampicin-associated pseudomembranous colitis are reported in the literature.1Boriello SP Jones RH Phillips I Rifampicin-associated pseudomembranous colitis.Br Med J. 1980; 281: 1180Crossref PubMed Scopus (19) Google Scholar, 2Fournier G Orgiazzi J Lenoir B Dechavanne M Pseudomembranous colitis probably due to rifampicin.Lancet. 1980; 1: 101Abstract Google Scholar, 3Melange M Vanheuverzwyn R Fiasse R Pseudomembranous colitis and rifampicin.Lancet. 1980; II: 1192Abstract Scopus (13) Google Scholar, 4Moriarty HJ Scobie BA Pseudomembranous colitis in a patient on rifampicin and ethambutol.N Zealand Med J. 1980; 91: 294Google Scholar Some reports do not document bacteriologic data.2Fournier G Orgiazzi J Lenoir B Dechavanne M Pseudomembranous colitis probably due to rifampicin.Lancet. 1980; 1: 101Abstract Google Scholar, 3Melange M Vanheuverzwyn R Fiasse R Pseudomembranous colitis and rifampicin.Lancet. 1980; II: 1192Abstract Scopus (13) Google Scholar, 4Moriarty HJ Scobie BA Pseudomembranous colitis in a patient on rifampicin and ethambutol.N Zealand Med J. 1980; 91: 294Google Scholar We report an additional case of pseudomembranous colitis apparently related to the administration of rifampicin in which Clostridium difficile and its toxin were isolated.CASE REPORTA 18-year-old woman was admitted on November 20, 1980 with a ten-day history of diarrhea and abdominal pain without fever and tenesmus. Since October 13 she had been treated for pulmonary tuberculosis with ethambutol (1,200 mg daily), rifampicin (600 mg daily) and isoniazid (300 mg daily). On October 30, isoniazid was stopped because of INH resistance; it was replaced by streptomycin (1 gm daily).During the three weeks before institution of antituberculosis chemotherapy she had been successively treated for intercurrent infections (urinary tract, genital tract), with TMP-SMZ, ampicillin, gentamicin and tinidazole and finally minocyclin (discontinued on October 20).A coloscopy performed on November 26 disclosed pseudomembranous colitis. Cl difficile and its toxin were isolated in the stool. Rifampicin was withdrawn and pyrazinamide (2 gm daily) and cholestyramine (12 gm daily) were administered. After three weeks of treatment, the patient became completely symptom-free. Cl difficile was no longer isolated, but the toxin remained present for two more weeks. Cholestyramine was discontinued on December 18.The patient was readmitted 20 days later for treatment of tuberculous meningitis that necessitated reinstitutiott of rifampicin; at the same time, pyrazinamide was withdrawn. The diarrhea did not return, but Cl difficile and its toxin reappeared transiently positive.DISCUSSIONRifampicin can be implicated in this case of pseudomembranous colitis because the patient had not received antimicrobials other than the antituberculosis chemotherapy for three weeks before she developed colitis. On the other hand, clinical and bacteriologic improvement had been observed when rifampicin was stopped. It is actually thought that proliferation of Cl difficile and production of its toxin occur when the normal bowel flora is suppressed or disturbed by antimicrobials. Ethambutol and streptomycin (parenteral) do not have great activity on bowel flora. The patient was treated with cholestyramine at the same time that rifampicin was withdrawn, but recent double-blind studies show that this agent is not more active than placebo in the treatment of pseudomembranous colitis.5Bartlett J Experimental studies and antibiotic associated colitis.Scandinav J Infect Dis (suppl). 1980; 22: 11Google Scholar When the patient was given rifampicin again, the stools were monitored for Cl difficile and its toxin; culture and toxin were transiently positive without bowel symptoms and became negative without treatment, in spite of rifampicin being continued. No explanation can be afforded this later finding. To the Editor: To our knowledge, only four cases of rifampicin-associated pseudomembranous colitis are reported in the literature.1Boriello SP Jones RH Phillips I Rifampicin-associated pseudomembranous colitis.Br Med J. 1980; 281: 1180Crossref PubMed Scopus (19) Google Scholar, 2Fournier G Orgiazzi J Lenoir B Dechavanne M Pseudomembranous colitis probably due to rifampicin.Lancet. 1980; 1: 101Abstract Google Scholar, 3Melange M Vanheuverzwyn R Fiasse R Pseudomembranous colitis and rifampicin.Lancet. 1980; II: 1192Abstract Scopus (13) Google Scholar, 4Moriarty HJ Scobie BA Pseudomembranous colitis in a patient on rifampicin and ethambutol.N Zealand Med J. 1980; 91: 294Google Scholar Some reports do not document bacteriologic data.2Fournier G Orgiazzi J Lenoir B Dechavanne M Pseudomembranous colitis probably due to rifampicin.Lancet. 1980; 1: 101Abstract Google Scholar, 3Melange M Vanheuverzwyn R Fiasse R Pseudomembranous colitis and rifampicin.Lancet. 1980; II: 1192Abstract Scopus (13) Google Scholar, 4Moriarty HJ Scobie BA Pseudomembranous colitis in a patient on rifampicin and ethambutol.N Zealand Med J. 1980; 91: 294Google Scholar We report an additional case of pseudomembranous colitis apparently related to the administration of rifampicin in which Clostridium difficile and its toxin were isolated. CASE REPORTA 18-year-old woman was admitted on November 20, 1980 with a ten-day history of diarrhea and abdominal pain without fever and tenesmus. Since October 13 she had been treated for pulmonary tuberculosis with ethambutol (1,200 mg daily), rifampicin (600 mg daily) and isoniazid (300 mg daily). On October 30, isoniazid was stopped because of INH resistance; it was replaced by streptomycin (1 gm daily).During the three weeks before institution of antituberculosis chemotherapy she had been successively treated for intercurrent infections (urinary tract, genital tract), with TMP-SMZ, ampicillin, gentamicin and tinidazole and finally minocyclin (discontinued on October 20).A coloscopy performed on November 26 disclosed pseudomembranous colitis. Cl difficile and its toxin were isolated in the stool. Rifampicin was withdrawn and pyrazinamide (2 gm daily) and cholestyramine (12 gm daily) were administered. After three weeks of treatment, the patient became completely symptom-free. Cl difficile was no longer isolated, but the toxin remained present for two more weeks. Cholestyramine was discontinued on December 18.The patient was readmitted 20 days later for treatment of tuberculous meningitis that necessitated reinstitutiott of rifampicin; at the same time, pyrazinamide was withdrawn. The diarrhea did not return, but Cl difficile and its toxin reappeared transiently positive. A 18-year-old woman was admitted on November 20, 1980 with a ten-day history of diarrhea and abdominal pain without fever and tenesmus. Since October 13 she had been treated for pulmonary tuberculosis with ethambutol (1,200 mg daily), rifampicin (600 mg daily) and isoniazid (300 mg daily). On October 30, isoniazid was stopped because of INH resistance; it was replaced by streptomycin (1 gm daily). During the three weeks before institution of antituberculosis chemotherapy she had been successively treated for intercurrent infections (urinary tract, genital tract), with TMP-SMZ, ampicillin, gentamicin and tinidazole and finally minocyclin (discontinued on October 20). A coloscopy performed on November 26 disclosed pseudomembranous colitis. Cl difficile and its toxin were isolated in the stool. Rifampicin was withdrawn and pyrazinamide (2 gm daily) and cholestyramine (12 gm daily) were administered. After three weeks of treatment, the patient became completely symptom-free. Cl difficile was no longer isolated, but the toxin remained present for two more weeks. Cholestyramine was discontinued on December 18. The patient was readmitted 20 days later for treatment of tuberculous meningitis that necessitated reinstitutiott of rifampicin; at the same time, pyrazinamide was withdrawn. The diarrhea did not return, but Cl difficile and its toxin reappeared transiently positive. DISCUSSIONRifampicin can be implicated in this case of pseudomembranous colitis because the patient had not received antimicrobials other than the antituberculosis chemotherapy for three weeks before she developed colitis. On the other hand, clinical and bacteriologic improvement had been observed when rifampicin was stopped. It is actually thought that proliferation of Cl difficile and production of its toxin occur when the normal bowel flora is suppressed or disturbed by antimicrobials. Ethambutol and streptomycin (parenteral) do not have great activity on bowel flora. The patient was treated with cholestyramine at the same time that rifampicin was withdrawn, but recent double-blind studies show that this agent is not more active than placebo in the treatment of pseudomembranous colitis.5Bartlett J Experimental studies and antibiotic associated colitis.Scandinav J Infect Dis (suppl). 1980; 22: 11Google Scholar When the patient was given rifampicin again, the stools were monitored for Cl difficile and its toxin; culture and toxin were transiently positive without bowel symptoms and became negative without treatment, in spite of rifampicin being continued. No explanation can be afforded this later finding. Rifampicin can be implicated in this case of pseudomembranous colitis because the patient had not received antimicrobials other than the antituberculosis chemotherapy for three weeks before she developed colitis. On the other hand, clinical and bacteriologic improvement had been observed when rifampicin was stopped. It is actually thought that proliferation of Cl difficile and production of its toxin occur when the normal bowel flora is suppressed or disturbed by antimicrobials. Ethambutol and streptomycin (parenteral) do not have great activity on bowel flora. The patient was treated with cholestyramine at the same time that rifampicin was withdrawn, but recent double-blind studies show that this agent is not more active than placebo in the treatment of pseudomembranous colitis.5Bartlett J Experimental studies and antibiotic associated colitis.Scandinav J Infect Dis (suppl). 1980; 22: 11Google Scholar When the patient was given rifampicin again, the stools were monitored for Cl difficile and its toxin; culture and toxin were transiently positive without bowel symptoms and became negative without treatment, in spite of rifampicin being continued. No explanation can be afforded this later finding.