Practice Guidelines for Clostridium Difficile-Associated Diarrhea and Colitis
American Journal of Gastroenterology Vol. 92, No. 5, 1997.
- 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
- 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.
- 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
- 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.
- Antibiotics should be discontinued if possible.
- Nonspecific supportive therapy should be given, and is often all that is
needed in treatment. Specific antibiotics should not be given routinely.
- When the diagnosis of C.difficile colitis is confirmed and specific
therapy is indicated, metronidazole given orally is preferred.
- 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.
- 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
- Reconfirm the diagnosis
- Discontinue medications that may be contributing to the diarrhea, and
treat the patient with nonspecific supportive therapy
- If specific therapy is needed, treat the patient with a standard course of
metronidazole given orally for 7 to 10 days, or with vancomycin.
- When possible, avoid treating (minor) infections with antibiotics for the
next 2 months after treatment of a relaps.
- 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.
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.