Eficácia da terapia antibiótica no tratamento da infecção por clostridioides difficile em pacientes com doença inflamatória intestinal: revisão sistemática

Abstract

Clostridioides difficile infection (CDI) is a clinically relevant complication in patients with inflammatory bowel disease (IBD), being associated with higher recurrence rates and worse clinical outcomes, particularly in ulcerative colitis. Evidence regarding the comparative effectiveness of antibiotics in this subgroup remains limited. This study aimed to compare the recurrence rates and outcomes of CDI in IBD patients treated with metronidazole, vancomycin, or fidaxomicin. A systematic review was conducted in accordance with PRISMA guidelines and registered in PROSPERO (CRD420250491687). Searches were performed in MEDLINE, EMBASE, PubMed, Cochrane Library, and Epistemonikos through September 2024. Observational studies including adults with confirmed IBD and CDI treated with metronidazole or vancomycin were eligible. Risk of bias was assessed using ROBINS-I. Outcomes included recurrence, clinical success, colectomy, and mortality. Nine studies were included, totaling 643 patients. Of these, 235 received metronidazole and 158 vancomycin as initial therapy. Recurrence occurred in 17.4% of metronidazole-treated patients and 8.2% of those treated with vancomycin. A random-effects meta-analysis of four studies (n=214) yielded OR = 0.55 (95% CI: 0.15–1.99; p = 0.36; I² = 66%), indicating no statistically significant difference, although a trend toward lower recurrence with vancomycin was observed. Colectomy occurred exclusively in ulcerative colitis cases, reinforcing the severity of this phenotype. Mortality was low and similar between groups. No eligible comparative studies evaluating fidaxomicin specifically in IBD were identified, preventing its inclusion despite its known role in reducing recurrence in the general population. In conclusion, no statistically significant superiority between vancomycin and metronidazole was demonstrated; however, the observed trend suggests potential therapeutic advantage of vancomycin, particularly in patients with active colitis and elevated recurrence risk. Heterogeneity among included studies limits definitive inferences. Prospective, stratified clinical trials are needed to guide optimal antibiotic selection in this highrisk population.