From the Guidelines
If a patient develops diarrhea after 4 days of IV ceftazidime, the first step is to evaluate for Clostridioides difficile infection (C. diff), which is a common complication of antibiotic therapy, and consider discontinuing ceftazidime if clinically appropriate. Obtain stool samples for C. diff testing immediately. While awaiting results, consider switching to an alternative antibiotic with less risk of causing antibiotic-associated diarrhea. Ensure the patient stays well-hydrated and monitor electrolytes, as diarrhea can cause significant fluid and electrolyte losses. If C. diff is confirmed, initiate treatment with oral vancomycin 125 mg four times daily for 10 days or fidaxomicin 200 mg twice daily for 10 days, as recommended by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 1. For mild cases not caused by C. diff, probiotics containing Lactobacillus or Saccharomyces boulardii may help restore normal gut flora, although evidence is limited 1. The diarrhea occurs because antibiotics like ceftazidime disrupt the normal intestinal microbiota, allowing opportunistic pathogens like C. diff to proliferate or causing dysbiosis that leads to altered gut function and diarrhea. Always document the reaction in the patient's chart to inform future antibiotic choices. In cases of recurrent C. diff infection, fecal microbiota transplantation is recommended for patients who have failed appropriate antibiotic treatments 1. Key considerations include:
- Discontinuing the offending antibiotic if possible
- Initiating appropriate treatment for C. diff if confirmed
- Maintaining hydration and monitoring electrolytes
- Considering alternative antibiotics or treatments for recurrent C. diff infection
- Documenting the reaction for future reference.
From the FDA Drug Label
Gastrointestinal Symptoms, reported in fewer than 2% of patients, were diarrhea (1 in 78), nausea (1 in 156), vomiting (1 in 500), and abdominal pain (1 in 416). The onset of pseudomembranous colitis symptoms may occur during or after treatment (see WARNINGS).
The patient should be monitored for signs of pseudomembranous colitis, and the treatment with cefazidime should be re-evaluated. If the diarrhea is severe or persistent, consideration should be given to discontinuing the cefazidime therapy 2.
From the Research
Patient Developed Diarrhea after 4 Days of IV Cefazidime
- The patient's diarrhea may be caused by Clostridium difficile infection, which is a common cause of antibiotic-associated diarrhea 3.
- The risk of C. difficile infection is dose-related and higher with longer courses and combination therapy of antibiotics 3.
- If the patient has mild C. difficile infection, treatment with oral metronidazole may be effective 3, 4, 5.
- For severe C. difficile infection, treatment with oral vancomycin may be more effective 3, 4, 5.
- Fidaxomicin may be an effective alternative for treating C. difficile infection 5.
- Teicoplanin may also be effective, but its availability and cost may be limiting factors 4, 5.
- It is essential to discontinue the contributing antibiotic, if possible, and to practice responsible antibiotic prescribing and vigilant handwashing to prevent the spread of C. difficile infection 3.
Treatment Options
- Metronidazole: effective for mild C. difficile infection, but may not be as effective as vancomycin for severe infection 4, 5.
- Vancomycin: effective for severe C. difficile infection, but may have a higher cost than metronidazole 4, 5.
- Fidaxomicin: effective for C. difficile infection, but may have a higher cost than vancomycin 5.
- Teicoplanin: may be effective, but its availability and cost may be limiting factors 4, 5.
Prevention
- Responsible antibiotic prescribing: essential to prevent the spread of C. difficile infection 3.
- Vigilant handwashing: essential to prevent the spread of C. difficile infection 3.
- Probiotics: may prevent antibiotic-associated diarrhea, but are not recommended specifically for preventing C. difficile infection 3.