Infectious Diseases I

iii.

Metronidazole is primarily only recommended in addition to oral vancomycin for the treatment

of severe-complicated/fulminant CDI. The IDSA guidelines indicate that metronidazole is

a valid treatment option for “initial episode, non-severe” CDI when fidaxomicin and oral

vancomycin are unavailable or for patients with limited access to resources to attain these

medications. Use of metronidazole as first-line therapy in patients with an initial episode of

mild-moderate CDI is also supported by the World Society of Emergency Surgery.

iv.

For enema volumes in patients requiring rectal instillation of vancomycin, location of CDI-

affected area(s) and risk of colonic perforation should be considered. Patients receiving

vancomycin enemas may need a cuffed rectal delivery device/tube to facilitate retention.

Patients with CDI-related colitis and proximal colonic diversion (i.e., no continuity with oral

or gastric route) may require rectal instillation of vancomycin enema.

vi.

Fecal transplantation has improved outcomes compared with oral vancomycin in noncritically

ill patients with recurrent CDI. Logistical challenges with product availability or stool

sample collection, fecal delivery and administration, and risk of colonization with pathogenic

organisms (e.g., E. coli) should be considered.

vii.

There are no definitive recommendations for duration of CDI antibiotic therapy or prevention

of recurrence when non-CDI antibiotic therapy is continued concurrently.

Response to therapy should be assessed by evaluating clinical signs and symptoms, including

resolution of diarrhea, laboratory abnormalities, sepsis, and related organ failure. Results of stool

testing for C. difficile in patients with resolution of disease do not predict recurrence.