Clostridium difficile infection medical therapy: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
m (Changes made per Mahshid's request)
 
(48 intermediate revisions by 4 users not shown)
Line 1: Line 1:
__NOTOC__
__NOTOC__
{{Clostridium difficile}}
{{Siren|Clostridium difficile infection}}
{{CMG}}; {{AE}} {{GRN}}
{{Clostridium difficile infection}}
{{CMG}}; {{AE}} {{GRN}}; {{YD}}


==Overview==
==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.
Treatment is generally recommended for average-risk patients who are symptomatic with positive lab findings for ''C. difficile'' infection. For patients with ''C. difficile'' [[Clostridium difficile risk factors|risk factors]], empiric therapy is recommended for symptomatic patients regardless of lab findings. Medical therapies for ''C. difficile'' infection include oral [[Metronidazole]] for mild to moderate infection, and oral [[Vancomycin]] plus intravenous [[Metronidazole]] for severe infection.


It is possible that mild cases do not need treatment.<ref name="pmid17636768">Nelson R. Antibiotic treatment for Clostridium difficile-associated diarrhea in adults. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004610. PMID 17636768</ref>
==Indications for Treatment==
===Symptomatic vs. Asymptomatic Individuals===
*Treatment is recommended only for average-risk, symptomatic patients (usually diarrhea) with positive lab findings (either ELISA or PCR) of ''C. difficile'' infection


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.
*In contrast, treatment is not recommended for average-risk, asymptomatic individuals OR patients with diarrhea and negative lab findings (either ELISA or PCR).


==Principles of Therapy for ''Clostridium difficile'' infection==
===Average Risk vs. High Risk Patients===
* If a patient has a strong pre-test probability for CDI, empiric therapy should be considered regardless of the laboratory testing result<ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 |pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>. CDI accounts for about 20% of antibiotic-associated diarrhoea cases in the USA<ref name="Planche2013">{{cite journal|last1=Planche|first1=Tim|title=Clostridium difficile|journal=Medicine|volume=41|issue=11|year=2013|pages=654–657|issn=13573039|doi=10.1016/j.mpmed.2013.08.003}}</ref>.The following table contains the main risk factors for CDI:<ref name="pmid22146873">{{cite journal| author=Hensgens MP, Goorhuis A, Dekkers OM, Kuijper EJ| title=Time interval of increased risk for Clostridium difficile infection after exposure to antibiotics. | journal=J Antimicrob Chemother | year= 2012 | volume= 67 | issue= 3 | pages= 742-8 | pmid=22146873 | doi=10.1093/jac/dkr508 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22146873  }} </ref><ref name="KnightSurawicz2013">{{cite journal|last1=Knight|first1=Christopher L.|last2=Surawicz|first2=Christina M.|title=Clostridium difficile Infection|journal=Medical Clinics of North America|volume=97|issue=4|year=2013|pages=523–536|issn=00257125|doi=10.1016/j.mcna.2013.02.003}}</ref><ref name="Planche2013">{{cite journal|last1=Planche|first1=Tim|title=Clostridium difficile|journal=Medicine|volume=41|issue=11|year=2013|pages=654–657|issn=13573039|doi=10.1016/j.mpmed.2013.08.003}}</ref><ref name="KnightSurawicz2013">{{cite journal|last1=Knight|first1=Christopher L.|last2=Surawicz|first2=Christina M.|title=Clostridium difficile Infection|journal=Medical Clinics of North America|volume=97|issue=4|year=2013|pages=523–536|issn=00257125|doi=10.1016/j.mcna.2013.02.003}}</ref><ref name="KnightSurawicz2013">{{cite journal|last1=Knight|first1=Christopher L.|last2=Surawicz|first2=Christina M.|title=Clostridium difficile Infection|journal=Medical Clinics of North America|volume=97|issue=4|year=2013|pages=523–536|issn=00257125|doi=10.1016/j.mcna.2013.02.003}}</ref>
 
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
*The [[negative predictive value]]s of the diagnostic lab tests (either ELISA or PCR) are sufficiently high > 95% for patients among patients with average risk of developing ''C. difficile'' infection. Accordingly, empiric therapy is not recommended if diagnostic lab tests yield negative findings among average-risk patients.
! style="width: 500px;background: #4479BA"|{{fontcolor|#FFF| '''''Risk factors for CDI'''''}}
 
|-
*In contrast the [[negative predictive value]]s of the diagnostic lab tests (either ELISA or PCR) are NOT sufficiently high for patients at high risk of ''C. difficile'' infection. Accordingly, empiric therapy is recommended for high risk patients with high pre-test probability even when lab findings yield negative results.<ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 |pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref> Common risk factors for the development of ''C. difficile'' infection are history of antibiotic administration within the past 12 weeks, advanced age > 65 years, immunodeficiency, exposure to healthcare facilities, or inflammatory bowel disease.
|  style="width: 120px;background: #F5F5F5"| Antibiotic exposure and the first three months after cessation of antibiotics, most ommonly [[clindamycin]], [[penicillins]], [[cephalosporins]], [[fluoroquinolones]],and multiple antibiotics
For more detailed list of ''C. difficile'' risk factors, click [[Clostridium difficile risk factors|here]]
|-
 
|  style="width: 120px;background: #DCDCDC"| Exposure to '''''[[Clostridium difficile]]''''': up to 25% of hospitalized patients and residents of lonf term facilities are colonized
==Principles of Antimicrobial Therapy for ''Clostridium difficile'' infection==
|-
According to the 2013 practice guidelines for the diagnosis, treatment, and prevention of ''C. difficile'' infections<ref name="KnightSurawicz2013" />, the choice of antimicrobial therapy is based on the severity of the clinical disease. Shown below is a table that defines the severity of ''C. difficile'' infection based on clinical features and lab findings:
|  style="width: 120px;background: #F5F5F5"| Age >65
|-
|  style="width: 120px;background: #DCDCDC"| History of [[inflammatory bowel disease]]
|-
|}


* Any antimicrobial agent should be discontinued<ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. |journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 | pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>.
{| style="font-size: 85%;"
* Current guidelines recommend to choose the treatment regimen based on the severity of the disease<ref name="pmid20307191">{{cite journal|author=Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC et al.| title=Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). |journal=Infect Control Hosp Epidemiol | year= 2010 | volume= 31 | issue= 5 | pages= 431-55 | pmid=20307191 | doi=10.1086/651706 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20307191  }} </ref> <ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 |pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref><ref name="Planche2013">{{cite journal|last1=Planche|first1=Tim|title=Clostridium difficile|journal=Medicine|volume=41|issue=11|year=2013|pages=654–657|issn=13573039|doi=10.1016/j.mpmed.2013.08.003}}</ref><ref name="KnightSurawicz2013">{{cite journal|last1=Knight|first1=Christopher L.|last2=Surawicz|first2=Christina M.|title=Clostridium difficile Infection|journal=Medical Clinics of North America|volume=97|issue=4|year=2013|pages=523–536|issn=00257125|doi=10.1016/j.mcna.2013.02.003}}</ref>:
! style="width: 80px; background: #4479BA; text-align: center;" |{{fontcolor|#FFF|Severity}}
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
! style="width: 720px; background: #4479BA; text-align: center;" | {{fontcolor|#FFF|Criteria}}
! style="width: 500px;background: #4479BA"|{{fontcolor|#FFF| '''''Severity of the disease'''''}}
|-
|-
| style="width: 120px;background: #F5F5F5"| '''Mild''': diarrhea as the only symptom
| style="background: #F5F5F5; padding: 5px; text-align: center;" | '''Mild'''
| style="background: #DCDCDC; padding: 5px;" | [[Diarrhea]] as the only [[symptom]]
|-
|-
| style="width: 120px;background: #DCDCDC"| '''Moderate''': raised white cell count but <15,000 cells/mL and serum creatine <1.5 times baseline
| style="background: #F5F5F5; padding: 5px; text-align: center;" | '''Moderate'''
| style="background: #DCDCDC; padding: 5px;" | Raised white cell count but <15,000 cells/mL and serum creatine <nowiki><1.5 times baseline</nowiki>
|-
|-
| style="width: 120px;background: #F5F5F5"| '''Severe''': leucocytosis >15,000 cells/mL OR serum creatinene level >1.5 times baseline or  abdominal tenderness and serum albumin < 3 g/dL
| style="background: #F5F5F5; padding: 5px; text-align: center;" | '''Severe'''
|-
| style="background: #DCDCDC; padding: 5px;" | [[Leucocytosis]] <nowiki>>15,000 cells/mL OR serum creatinene level >1.5</nowiki> times baseline or  abdominal tenderness and serum albumin < 3 g/dL
|  style="width: 120px;background: #DCDCDC"| '''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
|-
|-
| style="background: #F5F5F5; padding: 5px; text-align: center;" | '''Severe complicated'''
| style="background: #DCDCDC; padding: 5px;" | [[Hypotension]] or [[shock]], [[ileus]], [[megacolon]], [[leucocytosis]] >20,000 cells/mL OR [[leucopenia]] <nowiki><2,000, lactate ></nowiki>2.2 mmol/L, [[delirium]], [[fever]] ≥ 38.5 °C, organ failure
|}
|}


* Duration: recommendations stablish a 10-14 days treatment. If clinical response in 5-7 days, complete 10 days<ref name="KnightSurawicz2013">{{cite journal|last1=Knight|first1=Christopher L.|last2=Surawicz|first2=Christina M.|title=Clostridium difficile Infection|journal=Medical Clinics of North America|volume=97|issue=4|year=2013|pages=523–536|issn=00257125|doi=10.1016/j.mcna.2013.02.003}}</ref>.
<font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font><ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 |pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref><ref name="Planche2013">{{cite journal|last1=Planche|first1=Tim|title=Clostridium difficile|journal=Medicine|volume=41|issue=11|year=2013|pages=654–657|issn=13573039|doi=10.1016/j.mpmed.2013.08.003}}</ref><ref name="KnightSurawicz2013">{{cite journal|last1=Knight|first1=Christopher L.|last2=Surawicz|first2=Christina M.|title=Clostridium difficile Infection|journal=Medical Clinics of North America|volume=97|issue=4|year=2013|pages=523–536|issn=00257125|doi=10.1016/j.mcna.2013.02.003}}</ref><ref name="pmid20307191">{{cite journal|author=Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC et al.| title=Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). |journal=Infect Control Hosp Epidemiol | year= 2010 | volume= 31 | issue= 5 | pages= 431-55 | pmid=20307191 | doi=10.1086/651706 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20307191  }} </ref><ref name="pmid18971494">{{cite journal| author=Kelly CP, LaMont JT| title=Clostridium difficile--more difficult than ever. | journal=N Engl J Med |year= 2008 | volume= 359 | issue= 18 | pages= 1932-40 | pmid=18971494 | doi=10.1056/NEJMra0707500 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18971494  }} </ref>
* Do not use [[metronidazole]] beyond the first recurrence episode of CDI or for long-term therapy because of the risk of neurotoxicity<ref name="pmid20307191">{{cite journal|author=Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC et al.| title=Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). |journal=Infect Control Hosp Epidemiol | year= 2010 | volume= 31 | issue= 5 | pages= 431-55 | pmid=20307191 | doi=10.1086/651706 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20307191  }} </ref>.
* For mild-to-moderate patients who are intolerant/allergic to [[metronidazole]] and for pregnant/breastfeeding women, [[vancomycin]] is recommended.<ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 |volume= 108 | issue= 4 | pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>.
* The use of anti-peristaltic agents to control [[diarrhe]]a from confirmed or suspected CDI should be limited or avoided if possible.<ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 | pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>
* All patients with severe or severe complicated CDI shoulod have supportive care.<ref name="pmid23439232">{{cite journal|author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 | pages= 478-98; quiz 499 |pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>
* [[CT scanning]] of the abdomen and pelvis is recommended in patients with severe complicated CDI.<ref name="pmid23439232">{{cite journal|author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 | pages= 478-98; quiz 499 |pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>
* All patients with complicated CDI should have an evaluation from the surgery team.<ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 | pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 |pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }}</ref>
* If there is a third recurrence after a pulsed [[vancomycin]] regimen, fecal microbiota transplant should be considered<ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 | pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>.
 
==Medical Therapy==
<font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font><ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 |pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref><ref name="pmid20307191">{{cite journal|author=Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC et al.| title=Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). |journal=Infect Control Hosp Epidemiol | year= 2010 | volume= 31 | issue= 5 | pages= 431-55 | pmid=20307191 | doi=10.1086/651706 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20307191  }} </ref><ref name="Planche2013">{{cite journal|last1=Planche|first1=Tim|title=Clostridium difficile|journal=Medicine|volume=41|issue=11|year=2013|pages=654–657|issn=13573039|doi=10.1016/j.mpmed.2013.08.003}}</ref><ref name="KnightSurawicz2013">{{cite journal|last1=Knight|first1=Christopher L.|last2=Surawicz|first2=Christina M.|title=Clostridium difficile Infection|journal=Medical Clinics of North America|volume=97|issue=4|year=2013|pages=523–536|issn=00257125|doi=10.1016/j.mcna.2013.02.003}}</ref><ref name="pmid18971494">{{cite journal| author=Kelly CP, LaMont JT| title=Clostridium difficile--more difficult than ever. | journal=N Engl J Med |year= 2008 | volume= 359 | issue= 18 | pages= 1932-40 | pmid=18971494 | doi=10.1056/NEJMra0707500 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18971494  }} </ref>
{|
{|


Line 109: Line 99:


</div>
</div>
<div class="mw-customtoggle-table05" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">
<div class="mw-customtoggle-table05" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 225px; background:#4479BA;">


<font color="#FFF">
<font color="#FFF">
Line 198: Line 188:
|-
|-


| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=left | <SMALL><sup>†</sup> If '''''[[ileus]]''''' present, add'''''[[Vancomycin]] 500 mg in 100 mL NS per rectum q6h as retention enema'''''.</SMALL>
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=left | <SMALL><sup>†</sup> If '''''[[ileus]]''''' present, add '''''[[Vancomycin]] 500 mg in 100 mL normal saline per rectum q6h as retention enema'''''.</SMALL>


|-
|-
Line 261: Line 251:


|}
|}
===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.<ref name=Schwan_1983>{{cite journal | author = Schwan A, Sjölin S, Trottestam U, Aronsson B | title = Relapsing clostridium difficile enterocolitis cured by rectal infusion of homologous faeces. | journal = Lancet | volume = 2 | issue = 8354 | pages = 845 | year = 1983 | id = PMID 6137662}}</ref><ref name=Schwan_1994>{{cite journal | author = Paterson D, Iredell J, Whitby M | title = Putting back the bugs: bacterial treatment relieves chronic diarrhoea. | journal = Med J Aust | volume = 160 | issue = 4 | pages = 232-3 | year = 1994 | id = PMID 8309401}}</ref><ref name=Borody_2000>{{cite journal | author = Borody T | title = "Flora Power"-- fecal bacteria cure chronic C. difficile diarrhea. | journal = Am J Gastroenterol | volume = 95 | issue = 11 | pages = 3028-9 | year = 2000 | url = http://www.cdd.com.au/pdf/paper32.pdf | id = PMID 11095314}}</ref>
=== '''Duration of Antimicrobial Therapy''' ===
* Administer antimicrobial therapy for 10-14 days.
* Continue antimicrobial therapy only for 10 days if there is clinical improvement within 5 to 7 days.<ref name="KnightSurawicz2013">{{cite journal|last1=Knight|first1=Christopher L.|last2=Surawicz|first2=Christina M.|title=Clostridium difficile Infection|journal=Medical Clinics of North America|volume=97|issue=4|year=2013|pages=523–536|issn=00257125|doi=10.1016/j.mcna.2013.02.003}}</ref>
 
===Do's===
*Suspend other antibiotic therapies during administration of antibiotics to treat ''C. difficile'' infection.
*Administer [[vancomycin]] to patients with mild-to-moderate disease who are intolerant/allergic to [[metronidazole]] and for pregnant/breastfeeding women.<ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 |volume= 108 | issue= 4 | pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>.
*Deliver supportive care to patients with severe or severe complicated CDI .<ref name="pmid23439232">{{cite journal|author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 | pages= 478-98; quiz 499 |pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>
*Perform diagnostic abdominal CT scan for patients with worsening diarrhea and/or abdominal pain to rule out ''C. difficile''-associated complications.<ref name="pmid23439232">{{cite journal|author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 | pages= 478-98; quiz 499 |pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref> To learn more about the typical features of CDI on abdominal CT scan, click [[Clostridium difficile infection abdominal CT scan|here]]
*Request surgical consultation and perform routine pre-surgical work-up for patients suspected to have complicated ''C. difficile'' infection. To view indications for surgical management of ''C. difficile'' infection, click [[Clostridium difficile surgery|here]].
* Consider fecal microbiota transplant if there is a third recurrence after a pulsed [[vancomycin]] regimen.<ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 | pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>
* Consider vancomycin enema for patients whose oral antibiotic regimen cannot reach a segment of the colon, such as patients with Hartman's pouch, ileostomy, or colon diversion.
* Administer intravenous immunoglobulins for recurrent ''C. difficile ''infection only if patient has hypogammaglobulinemia.
* Manage ''C. difficile'' infection simultaneously with inflammatory bowel disease (IBD) flare-up among patients with IBD.
* Continue immunosuppressive medications for IBD patients with ''C. difficile'' infection.
 
===Don'ts===
*Do not administer [[metronidazole]] for a second recurrence episode of CDI or for long-term therapy because of the risk of neurotoxicity.<ref name="pmid20307191">{{cite journal|author=Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC et al.| title=Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). |journal=Infect Control Hosp Epidemiol | year= 2010 | volume= 31 | issue= 5 | pages= 431-55 | pmid=20307191 | doi=10.1086/651706 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20307191  }} </ref>
 
*Do not administer anti-peristaltic agents to treat [[diarrhea]] in patients with CDI.<ref name="pmid23439232">{{cite journal| author=Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH et al.| title=Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. | journal=Am J Gastroenterol | year= 2013 | volume= 108 | issue= 4 | pages= 478-98; quiz 499 | pmid=23439232 | doi=10.1038/ajg.2013.4 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23439232  }} </ref>
* Do not administer intravenous immunoglobulins for recurrent ''C. difficile ''infection, except if patient has hypogammaglobulinemia.
* Do not increase the dose of immunosuppressive medications for IBD patients with untreated ''C. difficile'' infection.
 
== Novel Pharmacologic Therapies ==
* In 2011, [[fidaxomicin]] was FDA-approved for the treatment of ''C. difficile'' infection.<ref name="pmid21288078">{{cite journal| author=Louie TJ, Miller MA, Mullane KM, Weiss K, Lentnek A, Golan Y et al.| title=Fidaxomicin versus vancomycin for Clostridium difficile infection. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 5 | pages= 422-31 | pmid=21288078 | doi=10.1056/NEJMoa0910812 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21288078  }} </ref>
** [[Fidaxomicin]] is a poorly absorbed, [[bactericidal]], [[macrocyclic]] antibiotic that acts against [[anaerobic]], [[gram-positive bacteria]].<ref name="pmid21288078">{{cite journal| author=Louie TJ, Miller MA, Mullane KM, Weiss K, Lentnek A, Golan Y et al.| title=Fidaxomicin versus vancomycin for Clostridium difficile infection. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 5 | pages= 422-31 | pmid=21288078 | doi=10.1056/NEJMoa0910812 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21288078  }} </ref>
** [[Fidaxomicin]] is non-inferior to vancomycin in the treatment of primary ''C. difficile'' infection.<ref name="pmid21288078">{{cite journal| author=Louie TJ, Miller MA, Mullane KM, Weiss K, Lentnek A, Golan Y et al.| title=Fidaxomicin versus vancomycin for Clostridium difficile infection. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 5 | pages= 422-31 | pmid=21288078 | doi=10.1056/NEJMoa0910812 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21288078  }} </ref>
** [[Fidaxomicin]] is associated with significantly reduced rate of recurrence compared with [[vancomycin]] (15% vs. 25%), except among patients infected with BI/NAP1/027 strain where the recurrence rate is statistically similar between both therapies.<ref name="pmid21288078">{{cite journal| author=Louie TJ, Miller MA, Mullane KM, Weiss K, Lentnek A, Golan Y et al.| title=Fidaxomicin versus vancomycin for Clostridium difficile infection. | journal=N Engl J Med | year= 2011 | volume= 364 | issue= 5 | pages= 422-31 | pmid=21288078 | doi=10.1056/NEJMoa0910812 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21288078  }} </ref>
 
==Fecal Bacteriotherapy==
* [[Fecal bacteriotherapy]] is a procedure related to probiotic research. It has been suggested as a potential cure for ''C. difficile ''infection.
* 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]].
 
==Treatment Regimen==
:* 1. '''Pseudomembranous colitis - mild to moderate'''<ref name="pmid25626036">{{cite journal| author=Bagdasarian N, Rao K, Malani PN| title=Diagnosis and treatment of Clostridium difficile in adults: a systematic review. | journal=JAMA | year= 2015 | volume= 313 | issue= 4 | pages= 398-408 | pmid=25626036 | doi=10.1001/jama.2014.17103 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25626036  }} </ref>
::* Preferred regimen: [[Metronidazole]] 500 mg PO tid for 10-14 days
::* Alternative regimen: [[Vancomycin]] 125 mg PO qid for 10-14 days
::* Note: If significant risk of recurrence: [[Vancomycin]] 125 mg PO qid for 10-14 days {{or}} [[Fidaxomicin]] 200 mg PO bid for 10 days
:* 2. '''Pseudomembranous colitis - severe'''<ref name="pmid25626036">{{cite journal| author=Bagdasarian N, Rao K, Malani PN| title=Diagnosis and treatment of Clostridium difficile in adults: a systematic review. | journal=JAMA | year= 2015 | volume= 313 | issue= 4 | pages= 398-408 | pmid=25626036 | doi=10.1001/jama.2014.17103 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25626036  }} </ref>
::* Preferred regimen: [[Vancomycin]] 125 mg PO qid for 10-14 days
::* Note: If significant risk of recurrence: [[Vancomycin]] 125 mg PO qid for 10-14 days {{or}} [[Fidaxomicin]] 200 mg PO bid for 10 days
:* 3. '''Pseudomembranous colitis - severe, complicated'''<ref name="pmid25626036">{{cite journal| author=Bagdasarian N, Rao K, Malani PN| title=Diagnosis and treatment of Clostridium difficile in adults: a systematic review. | journal=JAMA | year= 2015 | volume= 313 | issue= 4 | pages= 398-408 | pmid=25626036 | doi=10.1001/jama.2014.17103 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25626036  }} </ref>
::* Preferred regimen: [[Vancomycin]] 125-500 mg PO qid for 10-14 days {{and}} [[Vancomycin]] 500 mg diluted in 500 ml of saline as enema per rectum q6h {{and}} [[Metronidazole]] 500 mg IV q8h
::* Note: Consider urgent surgical consult
:* 4. '''Recurrent pseudomembranous colitis'''<ref name="pmid25626036">{{cite journal| author=Bagdasarian N, Rao K, Malani PN| title=Diagnosis and treatment of Clostridium difficile in adults: a systematic review. | journal=JAMA | year= 2015 | volume= 313 | issue= 4 | pages= 398-408 | pmid=25626036 | doi=10.1001/jama.2014.17103 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25626036  }} </ref>
::* 4.1 '''Treatment of first recurrence'''
:::* Preferred regimen: same as first episode or [[Fidaxomicin]] 200 mg PO bid for 10 days
::* 4.2 '''Treatment of second or subsequent recurrence'''
:::* Preferred regimen: [[Vancomycin]] 125 mg PO qid for 14 days {{then}} [[Vancomycin]] 125 mg PO tid for 7 days {{then}} [[Vancomycin]] 125 mg PO bid for 7 days {{then}} [[Vancomycin]] 125 mg PO qd for 7 days {{then}} [[Vancomycin]] 125 mg PO q48h for 7 days {{then}} [[Vancomycin]] 125 mg PO q72h for 7 days {{or}} [[Fidaxomicin]] 200 mg PO bid for 10 days
:::* Note: Consider expert consult for fecal microbiota transplantation


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
[[Category:Disease]]
[[Category:Disease]]
[[Category:Gastroenterology]]
[[Category:Gastroenterology]]
[[Category:Infectious disease]]
 
[[Category:Bacterial diseases]]
[[Category:Bacterial diseases]]
 
[[Category: Infectious Disease Project]]
{{WH}}
{{WH}}
{{WS}}
{{WS}}

Latest revision as of 17:26, 18 September 2017

Resident
Survival
Guide

C. difficile Infection Microchapters

Home

Patient Information

Overview

Historical Perspective

Pathophysiology

Causes

Classification

Differentiating Clostridium difficile infectionfrom other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Abdominal X Ray

Abdominal CT Scan

Other Imaging Findings

Biopsy

Treatment

Medical Therapy

Surgery

Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Clostridium difficile infection medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Clostridium difficile infection medical therapy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Clostridium difficile infection medical therapy

CDC on Clostridium difficile infection medical therapy

Clostridium difficile infection medical therapy in the news

Blogs on Clostridium difficile infection medical therapy

Directions to Hospitals Treating Clostridium difficile

Risk calculators and risk factors for Clostridium difficile infection medical therapy

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

Overview

Treatment is generally recommended for average-risk patients who are symptomatic with positive lab findings for C. difficile infection. For patients with C. difficile risk factors, empiric therapy is recommended for symptomatic patients regardless of lab findings. Medical therapies for C. difficile infection include oral Metronidazole for mild to moderate infection, and oral Vancomycin plus intravenous Metronidazole for severe infection.

Indications for Treatment

Symptomatic vs. Asymptomatic Individuals

  • Treatment is recommended only for average-risk, symptomatic patients (usually diarrhea) with positive lab findings (either ELISA or PCR) of C. difficile infection
  • In contrast, treatment is not recommended for average-risk, asymptomatic individuals OR patients with diarrhea and negative lab findings (either ELISA or PCR).

Average Risk vs. High Risk Patients

  • The negative predictive values of the diagnostic lab tests (either ELISA or PCR) are sufficiently high > 95% for patients among patients with average risk of developing C. difficile infection. Accordingly, empiric therapy is not recommended if diagnostic lab tests yield negative findings among average-risk patients.
  • In contrast the negative predictive values of the diagnostic lab tests (either ELISA or PCR) are NOT sufficiently high for patients at high risk of C. difficile infection. Accordingly, empiric therapy is recommended for high risk patients with high pre-test probability even when lab findings yield negative results.[1] Common risk factors for the development of C. difficile infection are history of antibiotic administration within the past 12 weeks, advanced age > 65 years, immunodeficiency, exposure to healthcare facilities, or inflammatory bowel disease.

For more detailed list of C. difficile risk factors, click here

Principles of Antimicrobial Therapy for Clostridium difficile infection

According to the 2013 practice guidelines for the diagnosis, treatment, and prevention of C. difficile infections[2], the choice of antimicrobial therapy is based on the severity of the clinical disease. Shown below is a table that defines the severity of C. difficile infection based on clinical features and lab findings:

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

▸ Click on the following categories to expand treatment regimens.[1][3][2][4][5]

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)

Duration of Antimicrobial Therapy

  • Administer antimicrobial therapy for 10-14 days.
  • Continue antimicrobial therapy only for 10 days if there is clinical improvement within 5 to 7 days.[2]

Do's

  • Suspend other antibiotic therapies during administration of antibiotics to treat C. difficile infection.
  • Administer vancomycin to patients with mild-to-moderate disease who are intolerant/allergic to metronidazole and for pregnant/breastfeeding women.[1].
  • Deliver supportive care to patients with severe or severe complicated CDI .[1]
  • Perform diagnostic abdominal CT scan for patients with worsening diarrhea and/or abdominal pain to rule out C. difficile-associated complications.[1] To learn more about the typical features of CDI on abdominal CT scan, click here
  • Request surgical consultation and perform routine pre-surgical work-up for patients suspected to have complicated C. difficile infection. To view indications for surgical management of C. difficile infection, click here.
  • Consider fecal microbiota transplant if there is a third recurrence after a pulsed vancomycin regimen.[1]
  • Consider vancomycin enema for patients whose oral antibiotic regimen cannot reach a segment of the colon, such as patients with Hartman's pouch, ileostomy, or colon diversion.
  • Administer intravenous immunoglobulins for recurrent C. difficile infection only if patient has hypogammaglobulinemia.
  • Manage C. difficile infection simultaneously with inflammatory bowel disease (IBD) flare-up among patients with IBD.
  • Continue immunosuppressive medications for IBD patients with C. difficile infection.

Don'ts

  • Do not administer metronidazole for a second recurrence episode of CDI or for long-term therapy because of the risk of neurotoxicity.[4]
  • Do not administer anti-peristaltic agents to treat diarrhea in patients with CDI.[1]
  • Do not administer intravenous immunoglobulins for recurrent C. difficile infection, except if patient has hypogammaglobulinemia.
  • Do not increase the dose of immunosuppressive medications for IBD patients with untreated C. difficile infection.

Novel Pharmacologic Therapies

Fecal Bacteriotherapy

  • Fecal bacteriotherapy is a procedure related to probiotic research. It has been suggested as a potential cure for C. difficile infection.
  • 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.

Treatment Regimen

  • 1. Pseudomembranous colitis - mild to moderate[7]
  • Preferred regimen: Metronidazole 500 mg PO tid for 10-14 days
  • Alternative regimen: Vancomycin 125 mg PO qid for 10-14 days
  • Note: If significant risk of recurrence: Vancomycin 125 mg PO qid for 10-14 days OR Fidaxomicin 200 mg PO bid for 10 days
  • 2. Pseudomembranous colitis - severe[7]
  • Preferred regimen: Vancomycin 125 mg PO qid for 10-14 days
  • Note: If significant risk of recurrence: Vancomycin 125 mg PO qid for 10-14 days OR Fidaxomicin 200 mg PO bid for 10 days
  • 3. Pseudomembranous colitis - severe, complicated[7]
  • Preferred regimen: Vancomycin 125-500 mg PO qid for 10-14 days AND Vancomycin 500 mg diluted in 500 ml of saline as enema per rectum q6h AND Metronidazole 500 mg IV q8h
  • Note: Consider urgent surgical consult
  • 4. Recurrent pseudomembranous colitis[7]
  • 4.1 Treatment of first recurrence
  • Preferred regimen: same as first episode or Fidaxomicin 200 mg PO bid for 10 days
  • 4.2 Treatment of second or subsequent recurrence
  • Preferred regimen: Vancomycin 125 mg PO qid for 14 days THEN Vancomycin 125 mg PO tid for 7 days THEN Vancomycin 125 mg PO bid for 7 days THEN Vancomycin 125 mg PO qd for 7 days THEN Vancomycin 125 mg PO q48h for 7 days THEN Vancomycin 125 mg PO q72h for 7 days OR Fidaxomicin 200 mg PO bid for 10 days
  • Note: Consider expert consult for fecal microbiota transplantation

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Surawicz CM, Brandt LJ, Binion DG, Ananthakrishnan AN, Curry SR, Gilligan PH; et al. (2013). "Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections". Am J Gastroenterol. 108 (4): 478–98, quiz 499. doi:10.1038/ajg.2013.4. PMID 23439232.
  2. ↑ 2.0 2.1 2.2 Knight, Christopher L.; Surawicz, Christina M. (2013). "Clostridium difficile Infection". Medical Clinics of North America. 97 (4): 523–536. doi:10.1016/j.mcna.2013.02.003. ISSN 0025-7125.
  3. ↑ Planche, Tim (2013). "Clostridium difficile". Medicine. 41 (11): 654–657. doi:10.1016/j.mpmed.2013.08.003. ISSN 1357-3039.
  4. ↑ 4.0 4.1 Cohen SH, Gerding DN, Johnson S, Kelly CP, Loo VG, McDonald LC; et al. (2010). "Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA)". Infect Control Hosp Epidemiol. 31 (5): 431–55. doi:10.1086/651706. PMID 20307191.
  5. ↑ Kelly CP, LaMont JT (2008). "Clostridium difficile--more difficult than ever". N Engl J Med. 359 (18): 1932–40. doi:10.1056/NEJMra0707500. PMID 18971494.
  6. ↑ 6.0 6.1 6.2 6.3 Louie TJ, Miller MA, Mullane KM, Weiss K, Lentnek A, Golan Y; et al. (2011). "Fidaxomicin versus vancomycin for Clostridium difficile infection". N Engl J Med. 364 (5): 422–31. doi:10.1056/NEJMoa0910812. PMID 21288078.
  7. ↑ 7.0 7.1 7.2 7.3 Bagdasarian N, Rao K, Malani PN (2015). "Diagnosis and treatment of Clostridium difficile in adults: a systematic review". JAMA. 313 (4): 398–408. doi:10.1001/jama.2014.17103. PMID 25626036.

Template:WH Template:WS

Retrieved from "https://www.wikidoc.org/index.php?title=Clostridium_difficile_infection_medical_therapy&oldid=1354703"