8
Treatment
Adult
➤ Discontinue therapy with the inciting antibiotic agent(s) as soon as
possible, since this may influence the risk of CDI recurrence (S-M).
➤ Antibiotic therapy for CDI should be started empirically for situations
where a substantial delay in laboratory confirmation is expected, or for
fulminant CDI* (W-L).
* Fulminant CDI, previously referred to as severe, complicated CDI, may be
characterized by hypotension or shock, ileus, or megacolon.
➤ For patients with an initial CDI episode, we suggest using fidaxomicin
rather than a standard course of vancomycin (C-M).
Comment: This recommendation places a high value in the beneficial effects and
safety of fidaxomicin, but its implementation depends upon available resources.
Vancomycin remains an acceptable alternative.
➤ In settings where access to vancomycin or fidaxomicin is limited, we
suggest using metronidazole for an initial episode of non-severe CDI*
only (W-H). The suggested dosage is metronidazole 500 mg orally 3
times per day for 10 days. Avoid repeated or prolonged courses due to
risk of cumulative and potentially irreversible neurotoxicity (S-M).
* See Table 3 for definition of CDI severity.
➤ For fulminant CDI,* vancomycin administered orally is the regimen of
choice (S-M). If ileus is present vancomycin can also be administered
per rectum (W-L). The vancomycin dosage is 500 mg orally 4 times per
day and 500 mg in approximately 100 mL normal saline per rectum
every 6 hours as a retention enema. Intravenously administered
metronidazole should be administered together with oral or rectal
vancomycin particularly if ileus is present (S-M).
Notes: The metronidazole dosage is 500 mg intravenously every 8 hours.
* Fulminant CDI is described above.
➤ If surgical management is necessary for severely ill patients, perform
subtotal colectomy with preservation of the rectum (S-M). Diverting
loop ileostomy with colonic lavage followed by antegrade vancomycin
flushes is an alternative approach that may lead to improved outcomes
(W-L).
➤ In patients with recurrent CDI episodes, we suggest fidaxomicin
(standard or extended-pulsed regimen) rather than a standard course
of vancomycin (C-L).
Comment: Vancomycin in a tapered and pulsed regimen or vancomycin as a
standard course are acceptable alternatives for a first CDI recurrence. For patients
with multiple recurrences, vancomycin in a tapered and pulsed regimen, vancomycin
followed by rifaximin, and fecal microbiota transplantation are options in addition
to fidaxomicin.
