RISK FACTORS
β’ Antibiotic exposure (prior 6 weeks) particularly: clindamycin, lincomycin, ampicillin, cephalosporins. However,
may also rarely occur with penicillins, erythromycin, sulfa-trimethoprim, chloramphenicol, tetracycline. In fact, nearly all antibiotics have been implicated.
β’ Cancer chemotherapy: fluorouracil, methotrexate, combination regimens.
β’ Recent surgery, especially bowel surgery
β’ Uremia or hemolytic-uremic syndrome
β’ Intestinal ischemia
β’ Shock
β’ Tube feedings
β’ Enemas
β’ GI stimulants
β’ Stool softener
β’ H2 blockers and antacids
β’ Immunocompromise (e.g., low CD4)
β’ Prolonged hospitalization
β’ Advancing age
β’ Hirschsprung
β’ Inflammatory bowel disease
GENERAL MEASURES
β’ Fluid replacement
β’ Fluid plus electrolyte therapy
β’ Discontinue antimicrobial agent
β’ Avoid anti-diarrheal agents
β’ Successful in 25%
β’ Do not treat asymptomatic carriers
SURGICAL MEASURES
β’ Colectomy, not diversion, may be required
β’ 1-3% of patients with severe colitis require emergency colectomy because of impending perforation, severe
ileus with megacolon, or refractory septicemia
ACTIVITY Bedrest during acute phase
DIET Nothing by mouth during fulminant phase
DRUG(S) OF CHOICE
If drugs are not able to be taken orally, give via NG, enema, or direct instillation by colostomy/ileostomy or IV
. Metronidazole (Flagyl) 500 mg po tid for 10-14 days
. Vancomycin
. 125 mg po qid (only for severe or resistant cases) for 10-14 days
. May increase dose to 500 mg qid if diarrhea, fever, and leukocytosis fail to abate after 48 hours
. Severely ill patients who do not respond to oral vancomycin may benefi t from addition of IV metronidazole
500 mg q8 hours
. Teicoplanin 50 mg po qid for 3 days then 100 mg bid for 4 days
Precautions: Avoid antiperistaltic drugs such as diphenoxylate, atropine, loperamide to reduce risk of toxic megacolon
ALTERNATIVE DRUGS
β’ Bacitracin 250,000 units qid
β’ For flora repletion: Lactobacilli capsules or Saccharomyces boulardii enema of mixed colonies
β’ For chronic recurrences, adjunct therapy with full colon irrigation with Golytely
PATIENT MONITORING Careful monitoring through fulminant phase
PREVENTION/AVOIDANCE
. Judicious use of antimicrobial agents
. Keep courses of antibiotics as brief as possible
. Avoidance of recurrences
. Prolonged therapy
. Lactobacillus
. Repletion of other organisms which compete with C. Difficile
. In children, some success with IV gamma globulin
POSSIBLE COMPLICATIONS
. Reactive arthritis; Reiter syndrome
. Hypoalbuminemia
. Ascites
. Dehydration, hypovolemia, shock
. Bowel perforation
. Toxic megacolon
. Ileus relapses - 20% due to vegetative spores
. Death
EXPECTED COURSE/PROGNOSIS
. If treated, usual improvement in 3 days and virtually all patients recover
. Resistance to antibiotic therapy (metronidazole or vancomycin) is rare. Failure to respond to treatment may reflect noncompliance with therapy, misdiagnosis, underlying IBD or irritable bowel syndrome or malabsorption.
. Relapses occur in 10-25% of cases of C. difficile colitis
. Symptoms usually appear a few days after completing therapy, but may appear up to 30 days later
. For treatment, repeat a 10-14 day course of metronidazole 500 mg tid
. Untreated, 10-30% mortality
. In severely ill, colectomy sometimes required
. Significant morbidity and mortality in critical ill patients
. Poor prognostic factors: hypoalbuminemia, rapid fall in albumin, over 3 antibiotics, persistent C. difficile toxin
after 7 days of treatment