Oral vancomycin & PSC-IBD

February 11, 2025

Issue 03

Clinical Question

How effective is oral vancomycin in PSC patients with IBD?

Editor’s Bottom Line

Although evidence remains limited, the potential efficacy of vancomycin for treating IBD aligns with a microbial paradigm of its pathogenesis, and other IBD therapies that target the microbiome.

Reference

Arbabzada N, Dennett L, Meng G, et al. The Effectiveness of Oral Vancomycin on Inflammatory Bowel Disease in Patients with Primary Sclerosing Cholangitis: A Systematic Review. Inflamm Bowel Dis. Epub ahead of print Nov 4, 2024. https://academic.oup.com/ibdjournal

Synopsis

To determine the efficacy of oral vancomycin as salvage therapy in refractory primary sclerosing cholangitis (PSC) patients with IBD, researchers at the University of Alberta systematically reviewed all studies on the topic published until March 2024. They identified nine relevant case reports, seven case series, three cohort studies and one randomized controlled trial (RCT).

In the nine case reports, patients ranged in age from 9 to 51 years of age. Oral vancomycin doses ranged from 250 mg daily to 3,000 mg daily. Eight of the nine cases reported clinical improvement, with responses occurring as early as 24 hours. Five of the nine case reports showed endoscopic improvement, and four had histologically quiescent disease after oral vancomycin.

Of the seven-case series, four included pediatric patients and three included adults. Ages ranged from 2 to 69 years and oral vancomycin doses ranged from 250 mg daily to 1,500 mg daily. Of the case series measuring clinical IBD symptoms, most reported an overall improvement with oral vancomycin, including one patient who responded within 24 hours. Two of the case series reported biochemical remission, while four case series reported endoscopic improvements as early as five months, with accompanying histological improvements.

The three cohort studies and one RCT included 422 pediatric and adult patients treated with oral vancomycin. In two of the cohort studies, roughly one quarter of patients were also receiving biologics, while the RCT and the third cohort study excluded patients receiving a biologic. Oral vancomycin doses in these publications ranged from 500 mg daily to 2,250 mg daily. The RCT and one of the cohort studies reported improvements in diarrhea. In one cohort study comparing patients treated with oral vancomycin, ursodeoxycholic acid or no therapy, all three treatment groups experienced improvements and colectomy rates were similar between the groups. Another cohort study found that oral vancomycin led to higher rates of clinical and endoscopic remission at one year, compared to similar patients not receiving oral vancomycin.

None of the publications detailed adverse drug reactions with oral vancomycin therapy.

Details

Study Design: Systematic review
Funding: None
Allocation: Not applicable
Setting: Single-center
Level of Evidence: 3b