Practice Guidelines for Clostridium Difficile-Associated Diarrhea and Colitis

American Journal of Gastroenterology Vol. 92, No. 5, 1997.

Diagnosis

1. The diagnosis should be suspected in anyone with diarrhea who has received Abx within the previous 2 months and/or whose diarrhea began 72H or more after hospitalization.
2. When the diagnosis of C. difficile is suspected, a single stool specimen should be sent to the laboratory for testing for the presence of C.difficile and/or its toxins.
3. If the results of those tests are negative but diarrhea persists, one or two additional stools can be sent for testing with the same or different tests.
4. Endoscopy is reserved for special situations, such as when a rapid diagnosis is needed and test results are delayed or the test is not highly sensitive, or the patient has ileus and a stool is not available, or when other colonic diseases are in the differential.

Treatment

1. Antibiotics should be discontinued if possible.
2. Nonspecific supportive therapy should be given, and is often all that is needed in treatment.  Specific antibiotics should not be given routinely.
3. When the diagnosis of C.difficile colitis is confirmed and specific therapy is indicated, metronidazole given orally is preferred.
4. If the diagnosis of C. difficile diarrhea is highly likely and the patient is seriously ill, metronidazole may be given empirically before the diagnosis is definitely established.
5. Vancomycin given orally is reserved for therapy of C. difficile associated diarrhea until one or more of the following conditions are present: (a) the patient has failed to respond to metronidazole, (b) the patient's organism is resistant to metronidazole, (c) the patient is unable to tolerate metronidazole, or is allergic to it, or is being treated with ethanol containing solutions, (d) the patient is pregnant or a child under the age of 10, (e) the patient is critically ill because of c diff colitis, (f) there is evidence suggesting the diarrhea is caused by staph aureus.

Management of Relapses

1. Reconfirm the diagnosis
2. Discontinue medications that may be contributing to the diarrhea, and treat the patient with nonspecific supportive therapy
3. If specific therapy is needed, treat the patient with a standard course of metronidazole given orally for 7 to 10 days, or with vancomycin.
4. When possible, avoid treating (minor) infections with antibiotics for the next 2 months after treatment of a relaps.
5. Not treatment available in the US has been proven to prevent recurrences.  If the patient has suffered from multiple recurrences, consider using one of the following antimicrobial regimens with or without one of the other therapeutic measures as an adjunct: (a) oral metronidazole (or vancomycin), (b) specific therapy with vanco or metronidazole for 1 to 2 months, either intermittently (such as every other day or week) or with gradual tapering, with or without adjunctive therapy with an oral anion-binding regimen such as cholestyramine or colestipol begun near the end of antimicrobial therapy and gradually tapered, (c) oral vanco plus rifampin, (d) oral yogurt, lactobacillus preparations, or lactobacillus GG, (e) Saccharomyces boulardi (500 mg BID) may be given for one month, (f) human immune globulin by IV infusion, for patients with documented deficiencies.

Of note:

Becaue there is no way to reliably eradicate the C. difficile carrier state, there is no good reason to obtain stool cultures to determine whether a patient is at high risk for relapse.

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