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The initial step in the treatment of Clostridium difficile infection (CDI) is cessation of the inciting antibiotic as soon as possible. Infection control practices must be implemented, including contact precautions and hand hygiene. Hand hygiene with soap and water may be more effective than alcohol-based hand sanitizers in removing C. difficile spores, since C. difficile spores are resistant to killing by alcohol. Therefore, use of soap and water is favored over alcohol-based hand sanitization in the setting of a CDI outbreak, although thus far no studies have demonstrated superiority of soap and water in non-outbreak settings
For initial treatment of nonsevere CDI
, we suggest oral metronidazole
For treatment of severe CDI
, we recommend vancomycin 125 mg four times daily for 10 to 14 days
). For patients with severe disease who do not demonstrate clinical improvement, we suggest treatment with oral vancomycin 500 mg four times daily
); fidaxomicin may be considered in patients who cannot tolerate vancomycin, although more data are needed.
In critically ill patients with fulminant or refractory disease, we suggest oral vancomycin 500 mg four times daily and intravenous metronidazole 500 mg every eight hours (Grade 2C); fidaxomicin may be considered in patients who cannot tolerate vancomycin, although more data are needed.
For treatment of severe disease in patients with profound ileus, we suggest addition of intracolonic vancomycin (Grade 2C), but there is risk of colonic perforation. Therefore, use of intracolonic vancomycin should be restricted to patients who are not responsive to oral therapy, and the procedure should be performed by personnel with expertise in administering enemas.
For treatment of a nonsevere initial recurrence of CDI
, we suggest oral metronidazole
). Alternatives include oral vancomycin or fidaxomicin.
For treatment of a second recurrence of CDI
, we suggest intermittent and tapering vancomycin therapy or fidaxomicin
). For treatment of subsequent recurrences of CDI
, we suggest administering either fidaxomicin or vancomycin followed by rifaximin (Grade 2C
We recommend urgent surgical evaluation for patients with a white blood cell count ≥20,000 cells/microL and/or a plasma lactate between 2.2 and 4.9 mEq/L (Grade 1B). In addition, surgical intervention should be strongly considered in the setting of peritoneal signs, severe ileus, or toxic megacolon.
therapies requiring further investigation prior to routine use include new antibiotic agents, binding resins, intravenous immunoglobulin, and fecal bacteriotherapy.
Guideline parameters for severe CDI include white blood cell count of >15,000 cells/microL, serum albumin <3 g/dL, and/or a serum creatinine level ≥1.5 times the premorbid level
Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) ... - PubMed - NCBI
Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. - PubMed - NCBI
In patients receiving antibiotics who are felt to be at increased risk for CDAD, we suggest coadministration of probiotics for prevention of CDAD (Grade 2B). Factors for consideration include prolonged duration of antibiotic therapy, local incidence of CDAD, and individual patient characteristics.
We suggest NOT administering adjunctive probiotics for routine treatment of CDAD (Grade 2C). Use of probiotics may be reasonable in patients with recurrent disease that is not severe, as long as there are no significant comorbidities.
A small number of case reports describing bacteremia or fungemia attributed to probiotics have been reported; Saccharomyces boulardii and Lactobacillus rhamnosus GG are the most common organisms. In almost all cases, patients who developed bacteremia or fungemia in the setting of probiotic therapy had severe comorbidities, were on immunosuppressive medication, had recent surgical intervention, or had recent prolonged hospitalization.