Clostridium difficile: Treatment
Stop inciting antibiotics if possible
- This is important in the re-establishment of normal colonic flora
- Decreases risk of disease relapse
- May be the only treatment necessary in very mild cases (diarrhea without fever or other symptoms)
Treatment with metronidazole or oral vancomycin
- Metronidazole is recommended as first-line therapy for most cases of mild-to-moderate disease. It is preferred to vancomycin due to issues of lower cost and concern for development of vancomycin-resistant enterococci in patients in vancomycin therapy.
- In early studies, metronidazole and vancomycin both had efficacy around 90%.
- Recent data suggests lower efficacy of metronidazole, with a 22% failure rate in a 2005 study by Musher and colleagues (1). Another retrospective study from Quebec in 2004 demonstrated lower risk of progression to complicated disease in patients who received vancomycin instead of metronidazole (2).
- Vancomycin should be considered for patients with severe disease or those refractory to metronidazole.
- Oral therapy is preferred to intravenous therapy for patients who can take oral medication. Rectally administered vancomycin may be used for patients who have ileus. Intravenous vancomycin is ineffective, as it does not penetrate into the colonic lumen.
Supportive care
- Provide fluid and electrolyte repletion as needed
- Avoid anti-peristaltic agents and opiates.
- Monitor clinical status closely, as disease can progress quickly and result in complications including sepsis, dehydration, peritonitis, paralytic ileus, toxic megacolon. High WBC (>20,000), high fever, elevated creatinine, and profuse diarrhea and abdominal pain are signs of progressive or severe disease.
- Consider surgical intervention if disease progresses on therapy, or toxic megacolon, peritonitis, or sepsis develop.
Asymptomatic Carriers
- There is no benefit to antibiotic treatment of asymptomatic Clostridium difficile carriers. Long-term carriage rates are not significantly altered with such treatment (3), and unnecessary antibiotic use can lead to a variety of problems.
Recurrent Disease
- Occurs in up to 20% of patients with C. difficile disease
- Initial recurrence should generally be treated with same antibiotic as used for original case.
- For patients with multiple recurrences or refractory disease, a number of options have been tried, including prolonged vancomycin taper, rifaximin, nitazoxanide, and other investigational approaches.
References:
1. Musher DM, Aslam S, Logan N. et al. Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis 2005; 40:1586-90.
2. Pépin J, Valiquette L, Alary ME, Villemure P, Pelletier A, Forget K, et al. Clostridium difficile-associated diarrhea in a region of Quebec from 1991 to 2003: a changing pattern of disease severity. CMAJ. 2004;171:466-72.
3. Johnson S et al. Treatment of asymptomatic Clostridium difficile carriers (fecal excretors) with vancomycin or metronidazole. A randomized, placebo-controlled trial. Ann Intern Med 1992; 117(4):297-302.
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