Clostridium difficile infection medical therapy

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

Overview

Many persons will also be asymptomatic and colonized with Clostridium difficile. Treatment in asymptomatic patients is controversial, also leading into the debate of clinical surveillance and how it intersects with public health policy.

It is possible that mild cases do not need treatment.

Patients should be treated as soon as possible when the diagnosis of Clostridium difficile colitis (CDC) is made to avoid frank sepsis or bowel perforation.

Principles of Therapy for Clostridium difficile infection

• 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 diarrhea cases in the USA.The following table contains the main risk factors for CDI:

Risk factors for CDI
Antibiotic exposure and the first three months after cessation of antibiotics, most ommonly clindamycin, penicillins, cephalosporins, fluoroquinolones,and multiple antibiotics
Exposure to Clostridium difficile: up to 25% of hospitalized patients and residents of lonf term facilities are colonized
Age >65
History of inflammatory bowel disease

• Any antimicrobial agent should be discontinued.
• Current guidelines recommend to choose the treatment regimen based on the severity of the disease:

Severity	Criteria
Mild	Diarrhea as the only symptom
Moderate	Raised white cell count but <15,000 cells/mL and serum creatine <1.5 times baseline
Severe	Leucocytosis >15,000 cells/mL OR serum creatinene level >1.5 times baseline or abdominal tenderness and serum albumin < 3 g/dL
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

• Duration: recommendations stablish a 10-14 days treatment. If clinical response in 5-7 days, complete 10 days.
• Do not use metronidazole beyond the first recurrence episode of CDI or for long-term therapy because of the risk of neurotoxicity.
• For mild-to-moderate patients who are intolerant/allergic to metronidazole and for pregnant/breastfeeding women, vancomycin is recommended..
• The use of anti-peristaltic agents to control diarrheaa from confirmed or suspected CDI should be limited or avoided if possible.
• All patients with severe or severe complicated CDI should have supportive care.
• CT scanning of the abdomen and pelvis is recommended in patients with severe complicated CDI.
• All patients with complicated CDI should have an evaluation from the surgery team.
• 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, add Vancomycin 500 mg in 100 mL normal saline 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)

Fecal Bacteriotherapy

Fecal bacteriotherapy, a procedure related to probiotic research, has been suggested as a potential cure for the disease. It involves infusion of bacterial flora acquired from the feces of a healthy donor in an attempt to reverse bacterial imbalance responsible for the recurring nature of the infection. It has a success rate of nearly 95% according to some sources.