What is the recommended treatment and management for a 59-year-old female with enterocolitis shown on computed tomography (CT) abdomen, and what if there's no improvement in 6 days?

From the Guidelines

For a 59-year-old female with enterocolitis confirmed by CT abdomen, the recommended initial treatment includes bowel rest, intravenous fluid resuscitation, and empiric antibiotic therapy, with a regimen such as metronidazole 500 mg orally three times daily for non-severe cases, as suggested by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidance document for Clostridium difficile infection (CDI) 1. The patient should be placed on nothing by mouth (NPO) status or clear liquids depending on severity, with IV fluids to maintain hydration and electrolyte balance.

• Empiric antibiotic therapy should include coverage for common enteric pathogens, and the choice of antibiotic should be guided by the severity of the disease and the potential cause, with metronidazole being a suitable option for non-severe cases, as per the ESCMID guidelines 1.
• Symptomatic treatment with antispasmodics and antiemetics should be provided as needed, but antiperistaltic agents and opiates should be avoided, as recommended by the ESCMID guidance document 1. If there's no improvement after 6 days, management should escalate to include:
• Repeat imaging to assess for complications like abscess formation or perforation
• Stool studies for specific pathogens if not already done
• Consideration of Clostridioides difficile testing
• Possible colonoscopy for direct visualization and biopsy
• Consultation with gastroenterology and infectious disease specialists
• Antibiotic coverage may need broadening or adjustment based on culture results, and in cases of severe disease or lack of response to initial therapy, vancomycin 125 mg qid orally for 10 days may be considered, as suggested by the ESCMID guidelines 1. In severe cases or those not responding to medical therapy, colectomy may be necessary, particularly if there are signs of perforation, systemic inflammation, or deteriorating clinical condition, as indicated by the ESCMID guidance document 1.

From the FDA Drug Label

Vancomycin Hydrochloride Capsules are indicated for the treatment of C. difficile-associated diarrhea. Vancomycin Hydrochloride Capsules are also used for the treatment of enterocolitis caused by Staphylococcus aureus (including methicillin-resistant strains) in adult and pediatric patients less than 18 years of age The recommended dose is 125 mg administered orally 4 times daily for 10 days for C. difficile-associated diarrhea, and 500 mg to 2 g administered orally in 3 or 4 divided doses for 7 to 10 days for staphylococcal enterocolitis.

The recommended treatment for a 59-year-old female with enterocolitis is vancomycin. The dosage for enterocolitis caused by Staphylococcus aureus is 500 mg to 2 g administered orally in 3 or 4 divided doses for 7 to 10 days. If there's no improvement in 6 days, the treatment plan should be reassessed, and consideration should be given to:

• Re-evaluating the diagnosis to ensure that the treatment is appropriate for the causative organism.
• Checking for complications or other factors that may be contributing to the lack of improvement.
• Consulting with a specialist or seeking further guidance from a healthcare professional. 2

From the Research

Recommended Treatment and Management

The recommended treatment and management for a 59-year-old female with enterocolitis shown on computed tomography (CT) abdomen depend on the severity of the infection and the presence of any underlying conditions.

• For an initial episode of non-severe Clostridioides difficile infection, oral vancomycin or oral fidaxomicin is recommended 3.
• Metronidazole is no longer recommended as first-line therapy for adults 3.
• Fecal microbiota transplantation is a reasonable treatment option with high cure rates in patients who have had multiple recurrent episodes and have received appropriate antibiotic therapy for at least three of the episodes 3.

Management if No Improvement in 6 Days

If there is no improvement in 6 days, the patient may require:

• Re-evaluation of the diagnosis and treatment plan 4, 5.
• Consideration of alternative treatments, such as fidaxomicin or teicoplanin, which have been shown to be effective in some cases 6.
• Hospitalization and close monitoring if the patient's condition worsens or if they develop severe symptoms, such as pseudomembranous colitis, colonic ileus, toxic megacolon, sepsis, or death 3.

Important Considerations

• Good antibiotic stewardship is a key strategy to decrease rates of C. difficile infection 3.
• Hands should be cleaned with either soap and water or an alcohol-based product, but during outbreaks soap and water is superior 3.
• The Infectious Diseases Society of America does not recommend the use of probiotics for prevention of C. difficile infection 3.