For specific therapy recommendations see Clostridium difficile management
What are the main clinical symptoms of Clostridium difficile infection (CDI)?
Clinical symptoms include: watery or loose stools (ie. more than three times/day); fever; nausea; abdominal pain or cramping.
Aside from antibiotic exposure what other factors put patients at increased risk for CDI?
The risk for disease increases with: increasing age, severity of underlying diseases, degree of immunocompromise, abdominal surgery or gastrointestinal procedures, presence of a nasogastric tube, anti-ulcer medications (eg. proton pump inhibitors), duration of hospital stay or living in a long term care facility or prior history of CDI.
How is CDI usually treated?
Initial therapy should, if possible, include discontinuing the inciting antibiotic regimen. CDI will resolve spontaneously in about 20% of patients within 2-3 days of discontinuing the offending antibiotic(s) but most patients require specific antibiotic therapy with po metronidazole or vancomycin for at least 10 days. After treatment, repeat Clostridium difficile testing is NOT recommended if the patients’ symptoms have resolved, as patients may remain colonized.
Do asymptomatic patients with a positive Clostridium difficile toxin test result require treatment?
No, patients without symptoms do NOT require treatment.
Which antibiotic is preferred in the treatment of mild to moderate CDI?
Metronidazole and vancomycin show similar efficacy in patients with mild infection. Due to the risk of emergence of VRE associated with excess vancomycin usage, metronidazole remains the preferred agent in patients with mild-to-moderate infection. Vancomycin may be considered as first line therapy in patients who are greater than 75 years old, have comorbidities or who are immunosuppressed. (Incidentally, a 14 day course of metronidazole 500 mg PO TID costs approximately $4.00 versus a 14 day course of vancomycin 125 mg PO QID which costs approximately $400.00.)
How long should patients with CDI be treated?
In order to reduce the likelihood of recurrence it is important that patients with CDI complete at least 10 days of therapy.
What antibiotic is preferred in the treatment of severe CDI?
Vancomycin is recommended as first line therapy in patients with severe infection because of quicker symptom resolution and lower risk of treatment failure.
How do you decide if the CDI is severe?
Determination of disease severity is based on clinicial judgement and may include any or all of: a marked peripheral leukocytosis; renal dysfunction; severe abdominal pain; fever; hypotension; ileus; or toxic megacolon.
In severely ill patients with CDI should any additional antibiotic therapy be considered along with the po vancomycin?
Severely ill patients with ileus may have markedly delayed passage of oral antibiotics from the stomach to the colon. These individuals may benefit from the addition of intravenous metronidazole at a dose of 500 mg every eight hours. Vancomycin therapy per rectum may also be considered although the safety and efficacy of this practice has not been established. Vancomycin 500 mg retention enemas may be given every 4 to 8 hours.
Is there any benefit to combining po metronidazole with po vancomycin in more severe infections?
No, there is no evidence that adding po metronidazole to po vancomycin improves outcomes.
When should surgery be considered?
Surgery should be considered in patients with severe CDI who fail to improve with medical therapy or if toxic megacolon or colonic perforation is suspected. Toxic megacolon should be considered if the patient develops abdominal distention with diminution of diarrhea; this may reflect paralytic ileus resulting from loss of colonic muscular tone.
What other conditions may resemble CDI?
The differential diagnosis for CDI includes: benign or simple antibiotic-associated diarrhea; acute and chronic diarrhea caused by other enteric pathogens; adverse drug reactions (other than antibiotics); ischemic colitis; idiopathic inflammatory bowel diseases; and intra-abdominal sepsis.
Is there any role for antimotility agents in the treatment of CDI?
These agents should be avoided. There is little evidence that such agents lead to symptomatic improvement and several anecdotes and case series have associated their use with the development of toxic megacolon in patients with CDI.
Is there any role for cholesytramine in the treatment of CDI?
This agent should also be avoided as it is of no proven benefit and may theoretically bind and reduce the activity of the antibiotic therapy.
What is the role of probiotics in the management of CDI?
A probiotic such as Saccharomyces boulardii (Florastor) 500 mg orally 2 times daily for at least 4 weeks maybe added as adjunctive therapy in recurrent CDI. However, the efficacy of probiotics in preventing recurrent CDI is not established because of inconsistent study results. Probiotics are generally safe but should NOT be prescribed to immunocompromised patients, to patients in critical care settings, to patients with central lines in place nor to patients with bloody diarrhea or severe abdominal pain. There have been reports of bacteremia and fungemia associated with probiotics in such settings.
How can CDI be prevented in hospitals?
A multifaceted approach of prudent antimicrobial use along with stringent infection control including appropriate hand hygiene, early institution of contact precautions and disinfection of rooms with a sporocidal agent are all essential in preventing CDI and controlling its spread.