From the Guidelines
No, patients with Clostridium difficile (C. diff) infection should not routinely be made nil per os (NPO). In fact, maintaining adequate nutrition is important for recovery from C. diff infection. Patients should continue oral intake as tolerated, focusing on a balanced diet that includes adequate protein and calories to support healing. Hydration is particularly important, as diarrhea from C. diff can lead to significant fluid losses. If patients are experiencing severe nausea or vomiting that prevents oral intake, temporary NPO status with IV hydration may be necessary, but this should be limited to the shortest duration possible. The primary treatment for C. diff infection is appropriate antimicrobial therapy, typically oral vancomycin (125 mg four times daily for 10-14 days), fidaxomicin (200 mg twice daily for 10 days), or in mild cases, metronidazole (500 mg three times daily for 10-14 days) 1. These medications work best when administered orally, as they need to reach the colon where the infection resides. Making a patient NPO would interfere with delivery of these oral medications to their site of action and potentially delay recovery.
Some key considerations in managing C. diff infection include:
- The use of antimicrobial therapy as the primary treatment
- The importance of maintaining adequate nutrition and hydration
- The potential need for temporary NPO status with IV hydration in cases of severe nausea or vomiting
- The role of fecal microbiota transplantation (FMT) in treating recurrent C. diff infection, particularly in patients who have failed to respond to antibiotic therapy 1
It's worth noting that the most recent and highest quality study on this topic is the 2021 clinical practice guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 1, which provides recommendations for the treatment of C. diff infection in adults. This guideline emphasizes the importance of using antimicrobial therapy as the primary treatment for C. diff infection, and highlights the potential role of FMT in treating recurrent infection.
From the Research
Management of C. diff Infection
- The management of Clostridiium difficile (C. diff) infection typically involves antibiotic therapy, with oral vancomycin or fidaxomicin being the preferred medications for a first episode 2, 3, 4.
- Metronidazole is no longer recommended as first-line therapy for adults due to its lower rates of treatment success compared to vancomycin 2, 3, 4.
- Fecal microbiota transplantation is a reasonable treatment option for patients who have had multiple recurrent episodes and have received appropriate antibiotic therapy for at least three of the episodes 2, 3, 4.
Nil Per Os (NPO) Status
- There is no direct evidence to suggest that patients with C. diff infection should be made nil per os (NPO) 2, 3, 4, 5, 6.
- The focus of treatment is on antibiotic therapy and supportive care, rather than restricting oral intake 2, 3, 4.
- Patients with severe C. diff infection may require close monitoring and supportive care, but NPO status is not a standard recommendation 4, 6.
Treatment Outcomes
- Fidaxomicin has been shown to be superior to metronidazole, vancomycin, or their combination for a sustained clinical response and in the prevention of recurrent C. diff infection in certain patient populations 6.
- The choice of antibiotic therapy should be based on the severity of the infection, the patient's medical history, and the presence of any underlying conditions 2, 3, 4.