Sandbox G

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Guillermo Rodriguez Nava, M.D. [2]

Principles of Therapy for Clostridium difficile infection

1. If a patient has a strong pre-test probability for CDI, empiric therapy should be considered regardless of the laboratory testing result. CDI accounts for about 20% of antibiotic-associated diarrhoea cases in the USA.The main risk factors for CDI are:
   1. Antibiotic exposure and the first three months after cessation of antibiotics. Commonly clindamycin, penicillins, cephalosporins, fluoroquinolones,and multiple antibiotics.
   2. Exposure to Clostridium difficile: up to 25% of hospitalized patients and residents of lonf term facilities are colonized.
   3. Age >65.
   4. History of inflammatory bowel disease.
2. Any antimicrobial agent should be discontinued.
3. Current guidelines recommend to choose the treatment regimen based on the severity of the disease :
   1. Mild: diarrhea as the only symptom.
   2. Moderate: raised white cell count but <15,000 cells/mL and serum creatine <1.5 times baseline.
   3. Severe: leucocytosis >15,000 cells/mL OR serum creatinene level >1.5 times baseline or abdominal tenderness and serum albumin < 3 g/dL.
   4. Severe complicated: hypotension or shock, ileus, megacolon, leucocytosis >20,000 cells/mL OR leucopenia <2,000, lactate >2.2 mmol/L, delirium, fever ≥ 38.5 °C, organ failure.
4. Duration: recommendations stablish a 10-14 days treatment. If clinical response in 5-7 days, complete 10 days.
5. Do not use metronidazole beyond the first recurrence episode of CDI or for long-term therapy because of the risk of neurotoxicity.
6. For mild-to-moderate patients who are intolerant/allergic to metronidazole and for pregnant/breastfeeding women, vancomycin should be used at standard dosing.
7. The use of anti-peristaltic agents to control diarrhea from confirmed or suspected CDI should be limited or avoided.
8. Supportive care should be delivered to all patients with severe or severe complicated CDI.
9. CT scanning of the abdomen and pelvis is recommended in patients with severe complicated CDI.
10. Surgical consult should be obtained in all patients with complicated CDI.
11. If there is a third recurrence after a pulsed vancomycin regimen, fecal microbiota transplant should be considered.

Medical Therapy

▸ Click on the following categories to expand treatment regimens.

Initial episode   ▸  Mild to moderate   ▸  Severe   ▸  Severe complicated Recurrence   ▸  First recurrence   ▸  Second recurrence

Mild to moderate Recommended treatment ▸ Metronidazole 500 mg orally q8h If no improvement in 5-7 days ▸ Vancomycin 125 mg orally q6h Severe Recommended treatment ▸ Vancomycin 125 mg orally q6h Severe complicated Recommended treatment† ▸ Vancomycin 500 mg orally q6h PLUS ▸ Metronidazole 500 mg IV q8h † If ileus present, addVancomycin 500 mg in 100 mL NS per rectum q6h as retention enema. First recurrence Recommended treatment ▸ Same as first episode but stratified by severity Second recurrence Recommended treatment ▸ Vancomycin in tapered and pulsed doses 125 mg 4 times daily for 14 days 125 mg 2 times daily for 7 days 125 mg once daily for 7 days 125 mg once every 2 days for 8 days (4 doses) 125 mg once every 3 days for 15 days (5 doses)