infectious diseases
Clostridioides (formerly Clostridium) difficile–Induced Diarrhea
Treatment ofClostridioides difficile–Induced Diarrhea
Oralvancomycinor oralfidaxomicin is recommended by the American College of Gastroenterology ( Treatment references ) for the treatment of a primary episode of nonsevere infection ( Treatment references ). Metronidazoleis no longer recommended as first-line therapy forC. difficile–induced diarrhea. However, oralmetronidazolecan be used ifvancomycinorfidaxomicinis not available. Vancomycin500 mg orally or by nasogastric tube 4 times a day andmetronidazole500 mg IV every 8 hours are recommended by the ISDA/SHEA for fulminant disease without ileus. 500 mg in 10 mL saline per rectum 4 times a day ( Treatment references ). If possibly causative antibiotics are being used, they should be stopped as soon as possible, or patients should be switched to an antibiotic regimen less likely to causeC. difficile–induced diarrhea. Cholestyramineresin,Saccharomyces boulardiiyeast, and probiotics have not been proved to be beneficial but are frequently added. Nitazoxanideappears to be comparable to oralvancomycinbut is not commonly used in the United States. A few patients require total colectomy for cure. ( Treatment references ). Infusion of donor feces (fecal transplant, usually done via colonoscopy) increases the likelihood of resolution in patients who have frequent recurrences; presumably, the mechanism is restoration of normalfecal microbiota. About 200 to 300 mL of donor feces are used; donors are tested for enteric and systemic pathogens. Feces can be infused using a nasal-duodenal tube, colonoscope, or enema; the optimal method has not been determined. Oralfecal microbiotatransplant capsules and afecal microbiotasuspension for rectal administration are commercially available. They can be given a few days after antibiotic treatment of recurrentC. difficileinfection to prevent recurrence. A human monoclonal antibody,bezlotoxumab10 mg/kg IV given once, binds to and neutralizesC. difficiletoxin B; it can be used for prevention of recurrentC. difficile–induced diarrhea along with standard-of-care treatment in patients who have had a recurrence within the last 6 months. Infection control measures are vital to reduce the spread ofC. difficileamong patients and health care workers. 1.Kelly CR, Fischer M, Allegretti JR, et al: ACG Clinical Guidelines: Prevention, diagnosis, and treatment ofClostridioides difficileinfections.Am J Gastroenterol116(6):1124–1147, 2021. doi: 10.14309/ajg.0000000000001278.Clarification and additional information.Am J Gastroenterol117(2):358, 2022. 2.Johnson S, Lavergne V, Skinner AM, et al: Clinical practice guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused update guidelines on management ofClostridioides difficileinfection in adults.Clin Infect Dis73(5):e1029–e1044, 2021. doi: 10.1093/cid/ciab549 