Initial treatment-clostridioides difficile infection

(CID 2021;73:5; Am J Gastro 2021;116:1124)

• If possible, d/c abx ASAP; stop antimotility agents & cholestyramine if using (binds vanco)
• Fidaxomicin is now preferred over vancomycin regardless of severity; may be limited by $
• Mild-mod: fidaxomicin 200 mg BID (↓ recurrence rate) or vanco 125 mg PO q6h × 10 d
• Severe (any of the following: >12 BM/d, Temp >103°F, WBC >15, HoTN, ICU care required, ileus): as above; could consider PO+PR vanco
• Fulminant disease: vanco 500 mg PO qid + MNZ 500 mg IV q8h; consider FMT
• If worsening (ileus, ↑ WBC, ↑ lactate, shock, toxic megacolon, peritonitis): abd CT & urgent surgical consult - subtotal colectomy, diverting loop ileostomy or colonic lavage
• If need to cont abx, cont C. diff. Rx for ≥7 d post-abx cessation (Am J Gastro 2016;111:1834)

參考➡️ Efficacy of secondary prophylaxis with vancomycin for preventing recurrent Clostridium difficile infections

• Stool carriage 3–6 wk postcessation; retesting for C. diff of limited utility during this time

Explain by ChatGPT

• Recurrence: treat as initial infection

The initial treatment for clostridioides difficile infection is to discontinue antibiotics as soon as possible. Antimotility agents and cholestyramine should also be stopped if they are being used, as vancomycin binds to them. Fidaxomicin is now the preferred treatment over vancomycin, regardless of severity. However, it may be limited by cost. For mild to moderate cases, fidaxomicin 200 mg twice daily is recommended, which decreases the recurrence rate. For severe cases, vancomycin 500 mg orally four times daily plus metronidazole 500 mg IV every 8 hours is recommended. If the condition worsens, an abdominal CT scan and urgent surgical consultation is advised, as subtotal colectomy, diverting loop ileostomy, or colonic lavage may be necessary. If antibiotics need to be continued, the clostridioides difficile treatment should be continued for at least 7 days after the antibiotics are discontinued. Stool carriage usually lasts 3-6 weeks after treatment cessation, and retesting for C. diff during this time is of limited utility. If there is a recurrence, it should be treated as an initial infection.

窩的英文不太好

• 復發：按初次感染處理

艱難梭菌感染的初始治療是盡快停用抗生素。如果正在使用抗動力劑和消膽胺，也應停用，因為萬古黴素會與它們結合。無論嚴重程度如何，非達黴素現在都是優於萬古黴素的首選治療方法。但是，它可能會受到成本的限制。對於輕度至中度病例，建議每天兩次使用非達黴素 200 mg，這可降低復發率。對於嚴重的病例，建議每天口服四次萬古黴素 500 毫克，每 8 小時一次靜脈注射甲硝唑 500 毫克。如果病情惡化，建議進行腹部 CT 掃描和緊急外科會診，因為可能需要進行結腸次全切除術、迴腸引流造口術或結腸灌洗。如果需要繼續使用抗生素，艱難梭菌治療應在停用抗生素後至少持續 7 天。大便通常在治療停止後持續 3-6 週，在此期間重新檢測艱難梭菌的作用有限。如有復發，應按初次感染處理。