From the Guidelines
The empirical treatment for suspected infectious colitis should be guided by the most recent and highest quality evidence, which recommends avoiding empirical therapy unless there is a strong suspicion for Clostridioides difficile infection (CDI) 1. When a strong suspicion for CDI exists, empirical therapy should be considered while awaiting test results. The choice of antibiotic therapy should be based on the severity of the disease, with metronidazole or oral vancomycin being options for mild to moderate cases, and vancomycin or fidaxomicin for severe cases 1. Key considerations in managing suspected infectious colitis include:
- Discontinuing antibiotic agents if possible, especially in cases of suspected severe CDI, as continued use of antibiotics for infections other than CDI is associated with an increased risk of CDI recurrence 1.
- Using antimicrobial therapy with agents less frequently implicated with antibiotic-associated CDI, such as parenteral aminoglycosides, sulfonamides, macrolides, vancomycin, or tetracycline/tigecycline, if continued antibiotic therapy is required 1.
- Avoiding the use of antiperistaltic agents and opiates, as they can worsen the condition 1.
- Implementing supportive care, including fluid rehydration and electrolyte replacement, and maintaining contact precautions to limit the transmission of C. difficile 1. The most recent guideline recommends metronidazole 500 mg tid orally for 10 days for non-severe CDI, and vancomycin 125 mg qid orally for 10 days for severe CDI 1. It is essential to adjust treatment based on culture results and to consider the severity of the disease when choosing antibiotic therapy. In cases where oral therapy is impossible, intravenous metronidazole or vancomycin via nasogastric tube may be considered 1. Overall, the management of suspected infectious colitis requires a comprehensive approach, considering the severity of the disease, the risk of CDI, and the need for supportive care.
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 empirical treatment for suspected infectious colitis is vancomycin. The recommended dose for adults 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. For pediatric patients, the usual daily dosage is 40 mg/kg in 3 or 4 divided doses for 7 to 10 days, not exceeding 2 g per day 2.
From the Research
Empirical Treatment for Suspected Infectious Colitis
The empirical treatment for suspected infectious colitis depends on the suspected pathogen and the patient's symptoms.
- For febrile dysenteric diarrhea, invasive bacterial enteropathogens such as Shigella, Salmonella, and Campylobacter should be suspected, and adults may be treated empirically with 1000mg azithromycin in a single dose 3.
- For Clostridioides difficile colitis, fidaxomicin is recommended as the first line of treatment, and vancomycin as a second choice, while metronidazole remains recommended only in cases where other treatments are not available 4.
- In some cases, metronidazole may still be proposed as first-line treatment, especially in patients without risk factors and with low probability of relapse 4.
- For pseudomembranous colitis, oral therapy with metronidazole 250 mg 4 times a day for 10 days is the recommended first-line therapy, while vancomycin should be limited to those who cannot tolerate or have not responded to metronidazole 5.
Special Considerations
- The choice of empirical treatment should take into account the patient's medical history, including recent antibiotic use and travel history 3.
- In cases where Clostridium difficile is suspected, it is essential to discontinue the use of the offending antibiotic and initiate treatment with an anticlostridial antibiotic 6.
- Recurrence of symptoms after antibiotics is common, and therapy with antibiotics in a pulsed or tapered regimen, as well as efforts to normalize the fecal flora, may be effective in preventing further recurrences 5.