Management of Recurrent C. difficile Infection

Diagnosis and Treatment

• For patients with recurrent diarrhea after completing vancomycin treatment for C. difficile infection, the next step should be to confirm recurrent C. difficile infection and then initiate fidaxomicin 200 mg twice daily for 10 days, as recommended by the Gastroenterology society 1
• The American Gastroenterological Association recommends verifying acute-onset, clinically significant diarrhea (≥3 unformed stools in 24 hours) and obtaining stool testing using a highly sensitive test combined with a highly specific test, to confirm recurrent C. difficile infection 1
• It is essential to rule out alternative diagnoses, especially in patients with bowel resection who may have other causes of diarrhea, according to the Gastroenterology society 1
• Assessment of severity should include checking for pseudomembranes on endoscopy, leukocytosis, low serum albumin, and rise in serum creatinine 2, 3
• Treatment options for CDI include:
• Patients with severe CDI may require vancomycin 500 mg four times daily by mouth or nasogastric tube, along with rectal instillation of vancomycin if ileus is present, and intravenous metronidazole 500 mg every 8 hours 4, 6, 2
• Monitoring for treatment response, with improvement expected within 2-3 days, and reassessing severity and considering alternative treatments if no improvement occurs within 48-72 hours, is essential for effective management, as suggested by the Infectious Diseases Society of America 7

Fecal Microbiota-Based Therapy

• The Gastroenterology society recommends fecal microbiota-based therapy upon completion of standard antibiotics, indicated after second recurrence (third episode) or in high-risk patients, with options including conventional fecal microbiota transplant (FMT) or FDA-approved products 1
• Fecal microbiota-based therapy should be given 1-3 days after completing antibiotics, with a recommended timing of 1 day after stopping antibiotics if bowel purge is given, or 3 days off antibiotics if no bowel purge, as suggested by the Gastroenterology society 1

Infection Control and Prevention

• Strict hand hygiene with soap and water, rather than alcohol-based sanitizers, is essential for preventing the spread of CDI, as recommended by the Centers for Disease Control and Prevention and the Infectious Diseases Society of America 7
• Contact precautions, including isolation and use of personal protective equipment, and thorough environmental cleaning are crucial for infection control, as noted by the Infectious Diseases Society of America 7
• The following table summarizes key infection control measures:

• Discontinuing the inciting antibiotic as soon as possible can reduce the risk of CDI recurrence, as noted by the Infectious Diseases Society of America 6, 9
• Risk factors for severe disease include age >60 years, fever, hypoalbuminemia, peripheral leucocytosis, ICU stay, and abnormal abdominal CT findings, as noted by the Infectious Diseases Society of America 6, 10, 11, 2

Special Considerations

• Patients on metronidazole should be monitored for peripheral neuropathy with prolonged therapy, and alternative treatments should be considered if no improvement occurs within 48-72 hours, as noted by the Infectious Diseases Society of America 3
• Patients over 65 years should be monitored for renal function during and after vancomycin treatment, due to the potential for nephrotoxicity, as noted by the Infectious Diseases Society of America 10, 9
• In children, metronidazole can be used at a dose of 7.5 mg/kg/dose (maximum 500 mg) three or four times daily for 10 days 5