Treatment for C. difficile Infection in Patients Unable to Take Oral Medications

Introduction to Treatment

The recommended treatment for patients with C. difficile infection who cannot take oral medications is intravenous metronidazole 500 mg three times daily for 10 days, plus either intracolonic vancomycin 500 mg in 100 mL of normal saline every 4-12 hours via retention enema or vancomycin 500 mg four times daily via nasogastric tube, as suggested by the Infectious Diseases Society of America 1, 2, 3

For non-severe C. difficile infection, intravenous metronidazole 500 mg three times daily for 10 days is recommended 1, 3
For severe C. difficile infection, intravenous metronidazole 500 mg three times daily for 10 days plus one or both of the following is recommended: intracolonic vancomycin 500 mg in 100 mL normal saline every 4-12 hours via retention enema or vancomycin 500 mg four times daily via nasogastric tube, according to the Society for Healthcare Epidemiology of America 1, 2, 3

Severe infection is characterized by one or more of the following: fever, hemodynamic instability, signs of peritonitis, signs of ileus, marked leukocytosis, serum creatinine rise, elevated serum lactate, or radiological evidence of colonic distension, as defined by the American College of Gastroenterology 3

For patients with recurrent C. difficile infection who cannot take oral medications, metronidazole 500 mg three times daily intravenously for 10-14 days plus intracolonic vancomycin 500 mg in 100 mL normal saline every 4-12 hours and/or vancomycin 500 mg four times daily via nasogastric tube is recommended, as suggested by the European Society of Clinical Microbiology and Infectious Diseases 1, 3

Consider colectomy in patients with perforation of the colon, systemic inflammation, toxic megacolon, or severe ileus, as recommended by the Surgical Infection Society 3
Fecal microbiota transplantation should be considered for patients with multiple recurrences who have failed appropriate antibiotic therapy, according to the International Society for Stem Cell Research 2, 5
Antiperistaltic agents and opiates should be avoided as they may worsen C. difficile infection, as warned by the American College of Physicians 1, 3
Discontinue the inciting antibiotic if possible, or switch to antibiotics less frequently associated with C. difficile infection, as advised by the World Health Organization 5
Treatment response should be assessed by decreased stool frequency and improved consistency within 3 days, with no new signs of severe colitis, as recommended by the Centers for Disease Control and Prevention 3