Clostridium difficile infection medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Guillermo Rodriguez Nava, M.D. [2]

Overview

Many persons will also be asymptomatic and colonized with Clostridium difficile. Treatment in asymptomatic patients is controversial, also leading into the debate of clinical surveillance and how it intersects with public health policy.

It is possible that mild cases do not need treatment.

Patients should be treated as soon as possible when the diagnosis of Clostridium difficile colitis (CDC) is made to avoid frank sepsis or bowel perforation.

Principles of Therapy for Clostridium difficile infection

• Empirical therapy should be initiated in a patient with high pre-test probabilities for CDI, despite the laboratory results. Up to 20% of antibiotic-associated diarrhea cases in the USA can be attributed to CDI .The following table contains the main risk factors for CDI:

Risk factors for CDI
Antibiotic exposure and the first three months after cessation of antibiotics, most commonly clindamycin, penicillins, cephalosporins, fluoroquinolones,and multiple antibiotics
Exposure to Clostridium difficile: up to 25% of hospitalized patients and residents of long term facilities are colonized
Age >65
History of inflammatory bowel disease

• Any other antibiotics should be suspended.
• Current guidelines recommend to choose the treatment regimen based on the severity of the disease:

Severity	Criteria
Mild	Diarrhea as the only symptom
Moderate	Raised white cell count but <15,000 cells/mL and serum creatine <1.5 times baseline
Severe	Leucocytosis >15,000 cells/mL OR serum creatinene level >1.5 times baseline or abdominal tenderness and serum albumin < 3 g/dL
Severe complicated	Hypotension or shock, ileus, megacolon, leucocytosis >20,000 cells/mL OR leucopenia <2,000, lactate >2.2 mmol/L, delirium, fever ≥ 38.5 °C, organ failure

• Duration: recommendations establish a 10-14 days treatment. Complete only 10 days of treatment if there is clinical improvement in 5-7 days.
• Metronidazole should not be used for a second recurrence episode of CDI or for long-term therapy because of the risk of neurotoxicity.
• Use vancomycin for mild-to-moderate patients who are intolerant/allergic to metronidazole and for pregnant/breastfeeding women ..
• If possible, do not use anti-peristaltic agents to treat diarrhea in a patient with CDI.
• Give supportive care to patients with severe or severe complicated CDI .
• Patients with severe complicated CDI should undergo CT scanning of the abdomen and pelvis.
• Patients with complicated CDI should have an evaluation from the surgery team.
• Indications for surgery: hypotension requiring vasopressor therapy; sepsis and organ failure; mental status changes; leukocytosis >50,500 cell/µl, lactate >5 mmol/l; or complicated infection without response of the medical therapy after 5 days.
• Fecal microbiota transplant can be considered if there is a third recurrence after a pulsed vancomycin regimen, .

Medical Therapy

▸ Click on the following categories to expand treatment regimens.

Initial episode   ▸  Mild to moderate   ▸  Severe   ▸  Severe complicated Recurrence   ▸  First recurrence   ▸  Second recurrence

Mild to moderate Recommended treatment ▸ Metronidazole 500 mg orally q8h If no improvement in 5-7 days ▸ Vancomycin 125 mg orally q6h Severe Recommended treatment ▸ Vancomycin 125 mg orally q6h Severe complicated Recommended treatment† ▸ Vancomycin 500 mg orally q6h PLUS ▸ Metronidazole 500 mg IV q8h † If ileus present, add Vancomycin 500 mg in 100 mL normal saline per rectum q6h as retention enema. First recurrence Recommended treatment ▸ Same as first episode but stratified by severity Second recurrence Recommended treatment ▸ Vancomycin in tapered and pulsed doses 125 mg 4 times daily for 14 days 125 mg 2 times daily for 7 days 125 mg once daily for 7 days 125 mg once every 2 days for 8 days (4 doses) 125 mg once every 3 days for 15 days (5 doses)

Fecal Bacteriotherapy

Fecal bacteriotherapy, a procedure related to probiotic research, has been suggested as a potential cure for the disease. It involves infusion of bacterial flora acquired from the feces of a healthy donor in an attempt to reverse bacterial imbalance responsible for the recurring nature of the infection. It has a success rate of nearly 95% according to some sources.