Antibiotic Treatment for Clostridium difficile Colitis
Disease Severity Assessment
- The European Society of Clinical Microbiology and Infectious Diseases recommends that non-severe C. difficile colitis be characterized by stool frequency < 4 times daily, no signs of severe colitis, and white blood cell count < 15 × 10^9/L 1
- Severe C. difficile colitis is characterized by one or more of the following: fever, hemodynamic instability, signs of peritonitis or ileus, marked leukocytosis, elevated serum creatinine, elevated serum lactate, or pseudomembranous colitis on endoscopy 1
First-Line Treatment Recommendations
- The Infectious Diseases Society of America recommends metronidazole 500 mg three times daily orally for 10 days as first-line therapy for non-severe C. difficile colitis (A-I) 2, 1
- Vancomycin 125 mg four times daily orally for 10 days is recommended for severe C. difficile colitis (A-I) 2, 1
- Consider stopping the inducing antibiotic and observing clinical response for 48 hours in non-epidemic situations, but follow patients closely for deterioration 2, 1
Treatment for Recurrent C. difficile Infection
- For second and subsequent recurrences, fidaxomicin 200 mg twice daily for 10 days (B-II) or vancomycin 125 mg four times daily for 10 days followed by either pulse or taper strategy (B-II) is recommended 2, 1
- For multiple recurrent CDI unresponsive to repeated antibiotic treatment, fecal transplantation in combination with oral antibiotic treatment is strongly recommended (A-I) 2
Important Considerations
- Avoid antiperistaltic agents and opiates in C. difficile infection 1
- Discontinue the inciting antibiotic if possible 1
Surgical Considerations
- Consider colectomy in situations such as perforation of the colon, systemic inflammation, toxic megacolon, or severe ileus 2, 1
- Surgery should preferably be performed before colitis becomes very severe (before serum lactate exceeds 5.0 mmol/L) 2, 1
Treatment of Clostridioides difficile Infection
Initial Treatment and Recurrence
- Fidaxomicin may be preferred over vancomycin for severe cases due to lower rates of secondary recurrences 3
- For second or subsequent recurrences, treatment options include oral vancomycin with a tapered and pulsed regimen, oral vancomycin followed by rifaximin, fidaxomicin, or fecal microbiota transplantation (FMT) 4
Fecal Microbiota Transplantation (FMT)
- FMT is strongly recommended for multiple recurrent CDI unresponsive to repeated antibiotic treatment 5, 6
- FMT should be offered to patients who have had at least two recurrences, or those who have had one recurrence and have risk factors for further episodes 6
- FMT should be given upon completion of a course of standard antibiotics for recurrent CDI, with antibiotics ideally stopped 1-3 days before conventional FMT 5
- Prevention of CDI recurrence following FMT ranges from 70% to 90% 4
Special Considerations
- In mildly or moderately immunocompromised adults with recurrent CDI, conventional FMT is suggested 5
- In severely immunocompromised adults with recurrent CDI, fecal microbiota-based therapies are not recommended 5