Management of initial episode and first recurrence of CDI
Mild to moderate CDI:
No features of severe CDI
- Oral or nasogastric Metronidazole 400mg q8h for 10-14 days.
- Metronidazole intolerance or contraindication: oral Vancomycin 125mg q6h for 10-14 days.
- Inability to take oral medication: intravenous Metronidazole 500mg q8h for 10-14 days.
- *Oral Fidaxomicin 200mg q12h for 10 days may be an alternative to Metronidazole or Vancomycin in patients aged 16 years and older but only following discussion with a clinical microbiologist or specialist ID consultant.
- Monitor closely for deterioration / progression to severe CDI
Severe CDI:
(suggested by any of the following)
- Clinical: fever, rigors, abdominal pain.
- Laboratory: Leukocytosis of >15x109/L, or a rise in serum creatinine of ≥50m% or serum creatinine >133µmol/L).
- Endoscopic findings: pseudomembranous colitis.
- Imaging: CT evidence of colitis or ascites
- Early surgical opinion.
- Oral Vancomycin 125mg q6h for 10-14 days.
- *Oral Fidaxomicin 200mg q12h for 10 days may be an alternative to Vancomycin in patients aged 16 years and older but only following discussion with a clinical microbiologist or specialist ID consultant.
Severe, complicated CDI:
Severe disease with:
- Hypotension.
- Shock.
- Rising serum lactic acid levels
- Ileus
- Megacolon
Management
- Early surgical opinion.
- Vancomycin 500mg q6h oral or nasogastric Plus Metronidazole 500mg q8h iv
- Consider intra-colonic Vancomycin 500mg q4-6h if ileus present or suspected
Mx of 2nd & subsequent episodes of recurrent CDI
Mild-moderate CDI:
Review all antimicrobial therapy and other medications. Ensure adequate fluid and electrolytes and review nutritional status
Contact clinical microbiologist or ID consultant for advice.
Consider the following options after expert advice as above:
- Oral Vancomycin tapering / pulse therapy (Grade D):
- 125mg q6h for 7 days, then
- 125mg q12h for 7 days, then
- 125mg q24h for 7 days, then
- 125mg every other day for 7 days, then
- 125mg every 3 days for 7 days
Or
- Oral Fidaxomicin 200mg q12h for 10 days (Grade D)
Or
- Oral Vancomycin 125mg q6h for 10 days followed by a course of oral Rifampicin 400mg q8h for 20 days (Grade B)
Or
- Intravenous immunoglobulin therapy 150-400micrograms/kg per day for 1 to 3 doses (Grade D)
Or
- Faecal microbiota transplantation (Grade A)
Severe or severe/complicated CDI:
Treat as first episode, Figure C1