Management of Pseudomembranous Colitis

Initial Assessment and Diagnosis

Discontinuation of the inciting antibiotic immediately upon suspicion of C. difficile infection is recommended, as continued antibiotic use significantly increases recurrence risk, according to the World Journal of Emergency Surgery 1, 2
If ongoing antibiotic therapy is essential for another infection, switching to agents less commonly associated with CDI, such as parenteral aminoglycosides, sulfonamides, macrolides, vancomycin, or tetracycline/tigecycline, is advised 1
Empirical therapy should be considered while awaiting test results only if there is strong clinical suspicion for severe CDI, defined by fever, leukocytosis, hypoalbuminemia, or ≥10 unformed bowel movements per day 1

Oral vancomycin 125 mg four times daily for 10 days is the preferred first-line treatment, particularly for severe disease, with clinical success rates of approximately 80% and superior efficacy compared to metronidazole in severe CDI 3, 4
Oral metronidazole remains effective for mild-to-moderate disease and offers advantages of lower cost and reduced selection pressure for vancomycin-resistant enterococci 3, 4
For patients with severe-complicated CDI showing signs of systemic toxicity, peritonitis, or worsening despite medical therapy, urgent surgical consultation is mandatory 1

For multiple recurrences (≥2 episodes), consideration of newer agents such as fidaxomicin or bezlotoxumab, which significantly reduce recurrence rates compared to vancomycin, is recommended 6
Fecal microbiota transplantation (FMT) should be considered after failure of three courses of antibiotics for recurrent CDI, with excellent success rates even after initial FMT failure 6

CT imaging assists with diagnosis and severity assessment in patients with clinical manifestations of severe-complicated disease, though sensitivity is only 52% 1, 2, 7
Point-of-care ultrasound may be useful in critically ill patients who cannot be transported to the CT suite, showing thickened colonic wall with heterogeneous echogeneity and hyperechoic pseudomembranes 1, 2, 7
Flexible sigmoidoscopy may be helpful when stool assays are negative but clinical suspicion remains high, though colonoscopy is hazardous in fulminant colitis due to perforation risk 1, 2, 7

Repeating testing after initiating treatment is not recommended unless there are clear clinical changes, as test positivity does not correlate with treatment failure 2, 7
Pseudomembrane formation may not be visible in neutropenic patients, requiring endoscopic biopsy for diagnosis in this population 5