What is the recommended initial treatment for a patient with confirmed Clostridioides difficile (C. difficile) colitis?

From the Guidelines

The patient should be started on fidaxomicin 200 mg twice daily for 10 days as the initial treatment for Clostridioides difficile colitis, as it is the preferred treatment according to the 2021 guidelines by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 1. The patient's presentation with a normal temperature, pulse rate, and blood pressure, and a soft, nondistended, and nontender abdomen, suggests a mild to moderate case of C. difficile colitis.

• The stool PCR is positive for C. difficile, confirming the diagnosis.
• The patient's laboratory results, including a leukocyte count of 8600 cells/μL and a serum creatinine level within normal limits, do not indicate severe disease.
• The 2021 IDSA and SHEA guidelines recommend fidaxomicin as the preferred treatment for initial C. difficile infection episodes, with vancomycin as an acceptable alternative 1.
• Fidaxomicin has been shown to have a lower recurrence rate compared to vancomycin, making it a better choice for initial treatment 1.
• The patient's presentation does not suggest fulminant C. difficile infection, which would require a different treatment approach, such as oral vancomycin 500 mg four times daily or a combination of intravenous metronidazole and oral vancomycin 1. Some key points to consider in the treatment of C. difficile colitis include:
• Discontinuing the inciting antibiotic, if possible, to reduce the risk of recurrence.
• Avoiding antimotility agents, which can worsen the condition.
• Providing supportive care, including fluid and electrolyte replacement, to manage symptoms and prevent complications.
• Monitoring the patient's response to treatment and adjusting the treatment plan as needed.

From the FDA Drug Label

Vancomycin Hydrochloride Capsules are indicated for the treatment of C. difficile-associated diarrhea. The recommended dose is 125 mg administered orally 4 times daily for 10 days.

The recommended initial treatment for a patient with confirmed Clostridioides difficile (C. difficile) colitis is to start treatment with oral vancomycin.

• The dose is 125 mg administered orally 4 times daily for 10 days.
• This treatment is indicated for the treatment of C. difficile-associated diarrhea, which includes colitis 2.

From the Research

Recommended Initial Treatment for Clostridioides difficile Colitis

The patient has been diagnosed with Clostridioides difficile (C. difficile) colitis, and the recommended initial treatment should be considered.

• The patient's symptoms and test results, including a positive stool PCR for C. difficile, indicate the need for effective treatment.
• According to the studies, oral vancomycin is a commonly recommended treatment for C. difficile colitis 3, 4, 5.
• The dosage of oral vancomycin can vary, but studies suggest that low-dose vancomycin (less than 2 g per day) may be as effective as high-dose vancomycin for treating initial episodes of non-fulminant C. difficile infection 3, 4.
• Another option for treatment is fidaxomicin, which has been recommended as a first-line treatment by some guidelines 6.
• However, the choice of treatment may depend on various factors, including the severity of the infection, patient comorbidities, and local resistance patterns.

Treatment Options

• Start treatment with oral vancomycin: This is a commonly recommended treatment for C. difficile colitis, and the patient's symptoms and test results indicate the need for effective treatment 3, 4, 5.
• Start treatment with oral fidaxomicin: This is another option for treatment, which has been recommended as a first-line treatment by some guidelines 6.
• Check stool for C. difficile toxins A and B: This test can help confirm the diagnosis of C. difficile colitis, but it is not necessary in this case since the patient already has a positive stool PCR result.
• Check stool for fecal calprotectin: This test can help assess the severity of inflammation in the colon, but it is not directly relevant to the treatment of C. difficile colitis.

The most appropriate recommendation for this patient would be to start treatment with oral vancomycin, as it is a commonly recommended and effective treatment for C. difficile colitis 3, 4, 5.