Toxin-Mediated Infections Clostridioides difficile Infection
GENERAL PRINCIPLES
The most frequently implicated antimicrobials associated with Clostridioides difficile infection (CDI) include clindamycin, fluoroquinolones, broad-spectrum penicillins, and cephalosporins.
DIAGNOSIS
Clinical Presentation
• Symptoms range from mild or moderate watery diarrhea to severe and potentially fatal pseudomembranous colitis. Abdominal pain, cramping, low-grade fever, and leukocytosis are often present.
• Fulminant disease can manifest as colonic ileus or toxic megacolon leading to bowel perforation.
Differential Diagnosis
Antibiotic-associated osmotic diarrhea without CDI should be considered and will resolve after withdrawal of the antibiotic.
Diagnostic Testing
Testing for CDI is recommended in patients with unexplained and new-onset diarrhea (≥3 unformed stools in 24 hours). Diagnosis is made by detection of toxigenic C. difficile in diarrheal stool through nucleic acid amplification test (NAAT) or enzyme immunoassay.
TREATMENT
• For an initial episode of CDI (severe or nonsevere), treatment should consist of vancomycin 125 mg PO q6h for 10 days or fidaxomicin 200 mg PO q12h for 10 days and discontinuation of the offending antibiotic if possible.2
• For fulminant infections complicated by ileus, toxic megacolon, hypotension, or shock, surgery consultation should be obtained along with treatment consisting of vancomycin 500 mg PO or by nasogastric tube q6h in combination with metronidazole 500 mg IV q8h. If ileus is present, consider adding rectal instillation of vancomycin. In some cases, colectomy may be necessary.2
• Endpoint of therapy is cessation of diarrhea; do not retest stool for toxin clearance.
• Avoid antimotility agents in severe disease.
• Recurrence is common and is treated with pulsed-tapered oral vancomycin or fidaxomicin if not previously used.
• Fecal microbiota transplantation may be considered for patients with multiple recurrences despite appropriate antibiotic treatment.2