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 ¶¶
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