Clostridium Difficile

Nonfulminant disease 

Initial episode (nonsevere or severe disease) 

Management of an initial CDI episode consists of treatment with an antibiotic regimen. 

Nonsevere disease is supported by the following clinical data: 

White blood cell count ≤15,000 cells/mL and serum creatinine level <1.5 mg/dL Severe disease* is supported by the following clinical data: 

White blood cell count >15,000 cells/mL and/or serum creatinine level ≥1.5 mg/dL 

Antibiotic regimens: 

Fidaxomicin 200 mg orally twice daily for 10 days Vancomycin 125 mg orally 4 times daily for 10 days 

For nonsevere disease, alternative regimen if above agents are unavailable: Metronidazole 500 mg orally 3 times daily for 10 to 14 days

Recurrent episode Management of a recurrent CDI episode consists of treatment with an antibiotic regimen, in addition to adjunctive bezlotoxumab if feasible. First recurrence Antibiotic regimens: Fidaxomicin 200 mg orally twice daily for 10 days, OR 200 mg orally twice daily for 5 days, followed by once every other day for 20 days Vancomycin in a tapered and pulsed regimen, for example: 125 mg orally 4 times daily for 10 to 14 days, then 125 mg orally 2 times daily for 7 days, then

125 mg orally once daily for 7 days, then 125 mg orally every 2 to 3 days for 2 to 8 weeks Vancomycin 125 mg orally 4 times daily for 10 days Adjunctive treatment: Bezlotoxumab 10 mg/kg intravenously, given once during administration of standard antibiotic regimen

Second or subsequent recurrence Antibiotic regimens: Fidaxomicin 200 mg orally twice daily for 10 days, OR 200 mg orally twice daily for 5 days, followed by once every other day for 20 days Vancomycin in a tapered and pulsed regimen (example as above) Vancomycin followed by rifaximin: Vancomycin 125 mg orally 4 times daily by mouth for 10 days, then Rifaximin 400 mg orally 3 times daily for 20 days Adjunctive treatment: Bezlotoxumab 10 mg/kg intravenously, given once during administration of standard antibiotic regimen. Role of fecal microbiota transplantation (FMT): For patients who have received appropriate antibiotic treatment for at least 3 CDI episodes (ie, initial episode plus 2 recurrences), who subsequently present with a fourth or further CDI episode (third or subsequent recurrence), we favor FMT in regions where available . Pending referral for FMT, we treat with an antibiotic regimen as outlined above. 

Fulminant disease Fulminant disease* is supported by the following clinical data: Hypotension or shock, ileus, megacolon Absence of ileus: Enteric vancomycin plus parenteral metronidazole : Vancomycin 500 mg orally or via nasogastric tube 4 times daily, AND Metronidazole 500 mg intravenously every 8 hours If ileus is present, additional considerations include: FMT (administered rectally)** OR Rectal vancomycin (administered as a retention enema 500 mg in 100 mL normal saline per rectum; retained for as long as possible and readministered every 6 hours) Δ ¶ ¥ ¶ Δ Δ ¶ ¥ ‡ † Δ ¶¶