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Sir,

Clostridium difficile-associated infection can result in diarrhoeal illness, colitis and death and is a major cause of morbidity and mortality in the UK.1 The main antibiotic treatments are metronidazole and vancomycin, but there is a lack of evidence for the superiority of one over the other.2 Metronidazole is usually preferred for first-line treatment of non-severe infection due to its lower cost and the potential of widespread vancomycin use to promote resistance in other organisms. Vancomycin is recommended in severe infection due to better clinical outcomes, although metronidazole resistance is not thought to be responsible for this.3 However, administration in such patients can often be problematic and both drugs may sometimes be prescribed in combination, so that if the enteral route becomes unavailable, parenteral metronidazole can be given (the efficacy of which has not been properly assessed).

We sought to examine the in vitro effect of these drugs in combination on C. difficile, to detect synergy or antagonism. Only one study has previously looked at the effect of antibiotics in combination, for rifampicin and metronidazole, and was conducted as a randomized trial. That study found no advantage in this combination.4

Issue Section:
Research Letters
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