Skin and Environmental Contamination With Vancomycin-Resistant Enterococci in Patients Receiving Oral Metronidazole or Oral Vancomycin Treatment for Clostridium difficile-Associated Disease

BACKGROUND. Oral metronidazole has been recommended for treatment of mild-to-moderate Clostridium difficile-associated disease (CDAD), in part because of concern that use of vancomycin may be more likely to promote colonization and transmission of vancomycin-resistant enterococci (VRE). The objective of our study was to compare the frequency of skin and environmental VRE contamination associated with metronidazole treatment for CDAD with such frequency associated with vancomycin treatment for CDAD. DESIGN. Prospective, observational study. This study was performed at the Cleveland Veterans Affairs Medical Center (Cleveland, OH). For patients with CDAD who had concurrent VRE colonization, stool, skin, and environmental samples were cultured for VRE before, during, and up to 3 weeks after therapy with metronidazole or vancomycin. The proportions of skin and environmental contamination were compared before and after resolution of diarrhea and during treatment with metronidazole or vancomycin. RESULTS. Of the 34 patients, 17 were treated with vancomycin and 17 were treated with metronidazole. The proportion of environmental cultures that were positive for VRE was significantly higher during resolution of diarrhea than it was after resolution of diarrhea (38% vs 28%; P = .025), whereas the proportion of skin cultures positive was not different during and after resolution of diarrhea (78% vs 71%; P = .60). There were no differences between patients who received metronidazole and patients who received vancomycin in the proportions of skin culture results (73% vs 77%; P = .80) or environmental culture results (37% vs 32%; P = .359) that were positive for VRE. Eleven patients (32%) had chronic fecal incontinence, and 28 (82%) had incontinence at least once during their CDAD episode. CONCLUSIONS. In VRE-colonized patients with CDAD who experienced frequent fecal incontinence, skin and environmental VRE contamination was common during and after resolution of diarrhea. The frequency of VRE contamination was similar between patients treated with metronidazole and patients treated with vancomycin.