From the Guidelines
The primary treatment for pseudomembranous colitis is stopping the causative antibiotic and starting oral vancomycin or fidaxomicin, with the most recent and highest quality study 1 supporting the use of fecal microbiota transplantation (FMT) for recurrent and refractory cases. For mild to moderate cases, oral metronidazole 500 mg three times daily for 10-14 days can be used, as recommended by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) 1. For severe cases, oral vancomycin 125 mg four times daily for 10-14 days is preferred, with the option of adding intravenous metronidazole 500 mg every 8 hours in fulminant cases 1. Fidaxomicin 200 mg twice daily for 10 days is an alternative with lower recurrence rates, and FMT has been shown to be effective in resolving recurrent and refractory CDI, with a clinical resolution rate of 92% 1. Supportive care includes fluid and electrolyte replacement, avoiding antimotility agents, and infection control measures to prevent spread. Some key points to consider when treating pseudomembranous colitis include:
- The importance of stopping the causative antibiotic to prevent further disruption of the gut flora
- The use of oral vancomycin or fidaxomicin as first-line treatment for mild to moderate cases
- The option of adding intravenous metronidazole in severe or fulminant cases
- The potential benefits of FMT for recurrent and refractory cases, with a clinical resolution rate of 92% 1
- The need for supportive care, including fluid and electrolyte replacement and infection control measures. It's also important to note that pseudomembranous colitis occurs when antibiotic use disrupts normal gut flora, allowing Clostridioides difficile to proliferate and produce toxins that damage the colon lining, forming characteristic pseudomembranes. In terms of FMT, the most recent study 1 suggests that it may be an effective option for patients with multiple recurrences of CDI who have failed appropriate antibiotic treatments, with a clinical resolution rate of 92%. Additionally, the study found that FMT was more effective than vancomycin in resolving recurrent and refractory CDI, with a relative risk of 0.23 (95% CI 0.07-0.80) 1. Overall, the treatment of pseudomembranous colitis should prioritize the use of oral vancomycin or fidaxomicin, with the option of adding intravenous metronidazole in severe or fulminant cases, and considering FMT for recurrent and refractory cases, as supported by the most recent and highest quality study 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.
The treatment for pseudomembranous colitis, which is often caused by C. difficile, is vancomycin administered orally. The recommended dose for adults is 125 mg four times daily for 10 days 2.
From the Research
Treatment Options for Pseudomembranous Colitis
- The standard therapy for the management of pseudomembranous colitis includes metronidazole or vancomycin 3.
- However, pseudomembranous colitis has a 15%-30% recurrence rate and can be refractory to standard treatments, resulting in morbidity and mortality 3.
- Fecal microbiota transplantation (FMT) has been shown to be an effective treatment for recurrent Clostridium difficile infection, including pseudomembranous colitis 3, 4.
- FMT via colonoscopy has been compared to vancomycin regimen in a randomised clinical trial, with FMT showing a significantly higher resolution rate of C. difficile-associated diarrhoea (90% vs 26%) 4.
- Other studies have also reported successful treatment of pseudomembranous colitis with FMT, including a study using push enteroscopy to infuse fecal microbiota 5.
- Endoscopic vancomycin sprinkling has also been reported as a successful treatment option for severe pseudomembranous colitis cases 6.
- Oral vancomycin has been shown to be effective in treating antibiotic-associated pseudomembranous colitis, with a good clinical response and rapid resolution of diarrhoea 7.