Sandbox G

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

Overview

1. If a patient has a strong pre-test probability for CDI, empiric therapy should be considered regardless of the laboratory testing result.
2. Any antimicrobial agent should be discontinued</ref> .
3. Current guidelines recommend to choose the treatment regimen based on the severity of the disease :
   1. Mild: diarrhea as only symptom.
   2. Moderate: raised WCC 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 >organ failure,; ≥ 38.5 °C.
4. Duration: recommendations stablish a 10-14 days treatment. If clinical response in 5-7 days, complete 10.
5. Do not use metronidazole beyond the first recurrence episode of CDI or for long-term therapy because of the risk of neurotoxicity (idsa).
6. For mild-to-moderate patients who are intolerant/allergic to metronidazole and for pregnant/breastfeeding women, vancomycin should be used at standard dosing</ref> .

1. The use of anti-peristaltic agents to control diarrhea from confirmed or suspected CDI should be limited or avoided</ref> .
2. Supportive care should be delivered to all patients with severe or severe complicated CDI</ref> .
3. CT scanning of the abdomen and pelvis is recommended in patients with severe complicated CDI</ref> .
4. Surgical consult should be obtained in all patients with complicated CDI</ref> .
5. If there is a third recurrence after a pulsed vancomycin regimen, fecal microbiota transplant should be considered</ref> .

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 Reommended 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)

References