Clostridium difficile Infection (CDI)

Treatment of Clostridium difficile infection

Indication/Severity

Definition

Rx

Dosage

 Response Rate
Mild Not severe criteria Stop inciting drugs
Test for CDI
Metronidazole		 500mg PO or IV Q6H 10-14 days 90%
Severe ICU admit, pseudomembranes on endoscopy,
age>60, temp>101.0 F,
serum albumin<2.5 mg/dL, WBC>15,000		 Vancomycin Oral 125 mg Q6H for 10-14 days 97%
First Recurrence Symptomatic CDI after completing
an initial course of metronidazole or vancomycin		 Metronidazole
Vancomycin		 500 mg po or IV Q6H 10-14 days
125 mg po Q6H 10-14 days		  
Second Recurrence Symptomatic CDI after completing
an second course of metronidazole or
vancomycin for recurrent CDI		 Vancomycin 125mg Q6H x14 days, then Q12H for 7 days, then Q24H for 7 days, then Q48H for 4 days, then Q72 H for 15 days 86%
Refractory or Fulminant Refractory: unresponsive to Vancomycin or metronidazole:

Fulminant: toxic megacolon with leukocytosis, hypotension, organ failure or anasarca

If ileus present or cannot tolerate oral Vancomycin, then add metronidazole

 Vancomycin

 

 

 

Metronidazole

 500 mg PO, intragastric or enema Q6H 10-14 days

 

 

 

500-750mg IV Q6H 10-14 days

  

Adapted from JAMA 2009;301(9):954-962,  A 76-Year-Old Man with Recurrent Clostridium difficile-Associated Diarrhea Review of C difficile Infection by Ciaran Kelly; from Clinical Crossroad's Clinician's Corner section.

Pathogenesis: gram positive spore-forming anaerobic bacillus, common in the general environment, carried by 1-4% of people, with normal flora conferring colonization resistance to the bacteria under normal conditions, loss of this resistance causes disease the state, of note clindamycin is prone to cause loss of resistance to the bug, development of the condition usually occurs shortly after antibiotic exposure, but may be delayed 2-3 months. Other things which may reduce colonization resistance include bowel preps for procedures, chemotherapy, and inflammatory bowel disease. Nearly any antibiotic can cause the condition.

Prevention: Avoid antibiotics; take probiotics containing lactobacilli or saccharomyces species along with the antibiotics. Hand washing using soap and water. Environmental cleaning using sporicidal agents such as bleach solutions (1part bleach to 10 parts water). Dedicated bathroom with frequent bleach cleansing. Transplantation of fresh feces into the gut to prevent a recurrence after treatment (experimental, but it worked well in a limited trial).

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