Clostridium difficile infection is a common nosocomial and community acquired diarrhea with an estimated 453,000 cases per year in the United States.
The treatment of CDI is based on its severity and recurrence risk.
CDI is diagnosed by but stool assay for the presence of the organism or its toxin in patients with otherwise unexplained diarrhea.
A white blood cell count of 15,000 or greater or a creatinine level greater than 1.5 mg/dL defines a severe CDI.
Fulminant infection is defined by the presence of hypotension, shock, ileum’s, or megacolon.
High-risk patients include those over age 65 and those who have had prior CDI, have severe CDI or are immunocompromised.
Vancomycin or fidaxomicin is recommended for initial treatment of nonsevere CDI.
Metronidazole is recommended only for low risk patients.
Fidaxomicin has been demonstrated to be noninferior to vancomycin for initial response and associated with fewer recurrences.
Fulminant CDI should be treated with high-dose vancomycin: lower mortality is associated with vancomycin and metronidazole versus vancomycin alone.
Vancomycin enemas are considered if ileus is present.
Severe or fulminant CDI refractory to antibiotic therapy maybe be treated with fecal microbiota transplantation.
Fecal microbiota transplantation is associated with a 75% efficacy rate for severe refractory CDI and when added to infusions after vancomycin it is been reported to be 100% effective.
For recurrent infection, tapered post vancomycin is recommended.
If vancomycin or metronidazole has been used and patients have recurrent CDI fidaxomicin is recommended.