Treatment of Clostridioides difficile Colitis

Disease Severity Assessment

The European Society of Clinical Microbiology and Infectious Diseases recommends that disease severity guides treatment selection, with non-severe C. diff infection characterized by stool frequency < 4 times daily, no signs of severe colitis, WBC < 15 × 10^9/L, and normal serum albumin and creatinine 2, 3, 4
Severe C. diff infection is defined by the presence of one or more of the following: fever > 38.5°C, marked leukocytosis (WBC > 15 × 10^9/L), serum albumin < 30 g/L, rise in serum creatinine (≥1.5 times baseline), hemodynamic instability, signs of peritonitis or ileus, or pseudomembranous colitis on endoscopy 2, 4, 5

The Infectious Diseases Society of America recommends metronidazole 500 mg orally three times daily for 10 days as first-line treatment for non-severe CDI, with vancomycin 125 mg orally four times daily for 10 days as an alternative 2, 4, 6
For severe CDI, vancomycin 125 mg orally four times daily for 10 days is recommended as first-line treatment, with fidaxomicin 200 mg orally twice daily for 10 days as an alternative 2, 4, 6

The American College of Gastroenterology recommends treating the first recurrence of CDI based on disease severity, with consideration of vancomycin or fidaxomicin instead of metronidazole even for non-severe cases 2, 3, 5
For second and subsequent recurrences, vancomycin 125 mg orally four times daily for at least 10 days is recommended, with consideration of vancomycin taper/pulse strategy or fidaxomicin due to lower recurrence rates 1, 2, 5

Surgical consultation should be obtained for patients with perforation of the colon, systemic inflammation and deteriorating clinical condition not responding to antibiotic therapy, toxic megacolon, or severe ileus 2, 4, 6
Surgery should be performed before colitis becomes very severe, ideally before serum lactate exceeds a certain threshold 2, 4

The Centers for Disease Control and Prevention recommends discontinuing the inciting antibiotic if clinically possible, avoiding antiperistaltic agents and opiates, and implementing infection control measures including hand hygiene with soap and water 2, 3, 5, 7

The Infectious Diseases Society of America recommends monitoring for clinical response within 3 days of treatment initiation, with treatment failure defined as absence of improvement after 3-5 days 3, 5