Management of C. difficile Infection

Disease Assessment and Diagnosis

The American Geriatrics Society recommends assessing for signs of severe disease, including fever, rigors, hemodynamic instability, signs of peritonitis or ileus, marked leukocytosis, and elevated serum creatinine 3
Evaluate severity of symptoms, as treatment recommendations differ based on disease severity, with consideration of factors such as age and comorbidities 1
Consider whether this represents recurrent C. difficile infection, defined as recurrence within 8 weeks of a previous episode, in patients with a history of CDI 4, 5

Provide supportive care, including intravenous fluid resuscitation to correct volume depletion, electrolyte replacement, and consideration of albumin supplementation if severe hypoalbuminemia is present 4, 5
Discontinue any unnecessary antibiotics if possible, as they can worsen C. difficile infection, and avoid antiperistaltic agents and opiates that can mask symptoms and potentially worsen the disease 6, 2

The Infectious Diseases Society of America recommends oral vancomycin 125 mg four times daily for 10 days as the preferred treatment for non-severe C. difficile infection in elderly patients, due to its superior efficacy and safety profile 1, 7
For severe disease, oral vancomycin 125 mg four times daily for 10 days is recommended, with consideration of intravenous metronidazole and vancomycin via nasogastric tube or rectal catheter if oral administration is not possible 1
For recurrent disease, oral vancomycin 125 mg four times daily for 14 days or fidaxomicin 200 mg twice daily for 10 days may be considered, with vancomycin in a tapered and pulsed regimen for multiple recurrences 4, 5

Elderly patients have higher mortality rates from C. difficile infection, with rates of asymptomatic C. difficile colonization in long-term care facilities approaching 10-30%, and may have atypical presentations, including severe leukocytosis without prominent diarrhea 3

Strict handwashing with soap and water is essential, as alcohol does not inactivate C. difficile spores, and isolation precautions should be implemented at first suspicion of CDI 3

Monitor for symptom resolution, and be vigilant for recurrence, which occurs in approximately 20-30% of patients after initial treatment, with consideration of abdominal imaging, flexible sigmoidoscopy, or surgical evaluation if symptoms worsen despite appropriate treatment 6, 7