Abstract
Keywords
To the Editor,
We read with great interest and no small concern the recent review by Sannaa et al. 1 on the use of oral vancomycin therapy (OVT) in primary sclerosing cholangitis (PSC) and associated inflammatory bowel disease (PSC-IBD). While we are encouraged by the growing body of literature demonstrating the effectiveness and safety of OVT, we are deeply disturbed by the inaccurate report of an 8% risk of vancomycin-resistant enterococcus (VRE) carriage in patients.
We acknowledge that the authors have submitted a corrigendum to their manuscript. However, we must stress that the fear surrounding VRE emergence is such that any figure suggesting an 8% VRE risk in PSC patients treated with OVT could severely compromise—if not entirely terminate—the potential for further investment in this valuable drug within this patient population.
It is therefore crucial that this misconception is clearly and promptly corrected, and that the correction is widely disseminated before it results in our infectious disease colleagues withdrawing their support for OVT. OVT holds promise as a therapy in PSC and PSC-UC, where no other treatments have demonstrated similar potential to improve patient outcomes. 2
We wish to restate that the finding of VRE cases in the recent review by Sannaa et al. 1 was based on preliminary data from an abstract of a study involving only 15 patients, where VRE was prematurely ascribed to 6 individuals. The subsequently completed analysis of the study, published in 2024, 3 confirmed that no evidence of VRE was found in these patients.
It is therefore vital to emphasize that the five studies referenced by Sannaa et al., 1 along with the large body of published (Table 1) and yet unpublished experience, have failed to demonstrate a single case of VRE emergence in the treatment of PSC and PSC-IBD. While the number of reported OVT treatments with VRE testing remains relatively small, the data available support that the emergence of VRE is a minimal risk both for patients and the broader community. The risk of VRE in this setting should not be overstated or incorrectly portrayed, as it could unnecessarily undermine a promising therapy for PSC and PSC-IBD.
Characteristics of studies reporting clinical response/remission to oral vancomycin in PSC and PSC-IBD.
Here are 15 additional studies (not counting the 6 abstractsa) combined with those in Sannaa et al. 1 None reported VRE or any adverse events.
Six abstracts not included (N = 71): Beedie 2024, Cintosun 2025, El-Youseff 2017, Higley 2020, Pratt 2011, Talamantes 2024.
“Stanford protocol”: 50 mg/kg if pt <30 kg divided into three doses; 1500 mg/day divided into three doses if pt ⩾30 kg.
The number of patients is only those who were treated with oral vancomycin (Deneau, DiGiorgio, Rahimpour, and Tabibian).
Atypical UC is defined as reverse gradient, right-sided, or patchy colitis with/without rectal sparing and/or backwash ileitis, and expressing atypical ANCA serology (pANCA).
IBD, inflammatory bowel disease; NR, not reported; PSC, primary sclerosing cholangitis; VRE, vancomycin-resistant enterococcus; BID, twice daily; QID, four times daily; TID, three times daily.
