Medical Management of Initial Episode of Clostridioides Difficile Infection
Management of initial CDI in the IBD population can be challenging, as symptoms may be due in part to both infection and exacerbation of the underlying IBD. Regardless, all symptomatic IBD patients with confirmed CDI by stool testing should receive appropriate antimicrobial therapy, which is guided by data from the general population. The Infectious Diseases Society of America defines the initial episode of CDI as nonsevere, severe, or fulminant. Nonsevere disease includes patients with a white blood cell count of 15 000 cells/ml or less and serum creatinine less than 1.5 mg/dl, severe disease includes those with white blood cell count more than 15 000 cells/ml and/or serum creatinine at least 1.5 mg/dl, and fulminant colitis includes those with hypotension, ileus, or toxic megacolon.
IBD patients with an initial episode of either nonsevere or severe CDI should be treated with oral vancomycin 125 mg four times daily for 10 days or fidaxomicin 200 mg twice daily for 10 days. Metronidazole is no longer recommended as first-line therapy given higher failure rates with this drug.[23,38,39] Fidaxomicin, which is bactericidal against C. difficile, appears to have a lower rate of posttreatment recurrence, but its significantly higher cost compared with oral vancomycin currently limits its use.[40,41] A recent retrospective study has identified a lower rate of CDI recurrence among IBD patients initially treated with long-duration (21–42 days) as opposed to short duration (10–14 days) oral vancomycin, however these results require validation in prospective trials. IBD patients who fail to demonstrate clinical improvement with appropriate antimicrobial therapy may require concomitant escalation of immunosuppressive therapy, which will be discussed separately.
All patients with fulminant CDI should be treated with vancomycin administered orally or via nasogastric tube 500 mg four times daily and intravenous metronidazole 500 mg every 8 h. Most patients with fulminant CDI should also receive intracolonic vancomycin administered rectally, as ileus is common and may be underrecognized. Those with fulminant disease also need serial abdominal examinations to detect the development of toxic megacolon or bowel perforation which could indicate emergent colectomy. The development of altered mental status, fever, cardiorespiratory failure, lactic acidosis, and worsening leukocytosis are poor prognostic indicators which may help identify individuals in whom to consider early surgical intervention.[43–47] There is also retrospective data that suggest a mortality benefit for use of early fecal microbiota transplantation (FMT) in place of colectomy for fulminant CDI, however prospective trials are needed to confirm these findings.[48,49] Additional indications for FMT will be discussed separately.
Curr Opin Gastroenterol. 2021;37(4):336-343. © 2021 Lippincott Williams & Wilkins