Treatment for Laboratory-Confirmed C. difficile Infection
Initial Treatment Recommendations
- The Infectious Diseases Society of America recommends oral vancomycin 125 mg four times daily for 10 days or fidaxomicin 200 mg twice daily for 10 days as first-line treatment for non-severe or severe initial CDI episode in a patient with normal kidney function 1, 2, 3
- The Society for Healthcare Epidemiology of America suggests that vancomycin and fidaxomicin are equally recommended as first-line options for non-severe or severe initial CDI episode 1, 2
Disease Severity Assessment
- Non-severe CDI is defined as WBC ≤15,000 cells/mL and serum creatinine <1.5 mg/dL 2, 3
- Severe CDI is defined as WBC ≥15,000 cells/mL or serum creatinine >1.5 mg/dL 2, 3
- Fulminant CDI is characterized by hypotension, shock, ileus, or megacolon 2, 3
Treatment Recommendations by Severity
- For fulminant CDI, vancomycin 500 mg orally four times daily is recommended 2, 3
- If ileus is present, rectal vancomycin 500 mg in 100 mL normal saline every 6 hours as retention enema is added to the treatment regimen 2, 3
- Concurrent intravenous metronidazole 500 mg every 8 hours is also recommended for fulminant CDI 2, 3
Important Clinical Considerations
- Discontinuing the inciting antibiotic as soon as possible reduces the risk of recurrence 2, 3
- Metronidazole should be avoided as first-line therapy due to lower efficacy and risk of cumulative neurotoxicity 1, 2, 3
- Treatment duration may be extended to 14 days if response to treatment is delayed 2, 3
Management of Recurrent CDI
- For first recurrence, vancomycin 125 mg four times daily for 10 days or fidaxomicin 200 mg twice daily for 10 days is recommended 1, 2
- For second or subsequent recurrence, a tapered and pulsed vancomycin regimen or vancomycin followed by rifaximin may be considered 1, 2
- Fecal microbiota transplantation may be considered after at least 2 recurrences 1, 2