From the Guidelines
Pseudomembranous colitis, also known as Clostridioides difficile-associated colitis, should be treated with oral vancomycin 125 mg four times daily for 10-14 days for severe cases, as recommended by the most recent and highest quality study 1.
Diagnosis and Treatment
The diagnosis of pseudomembranous colitis involves identifying the presence of Clostridioides difficile infection, typically through stool tests or colonoscopy. Treatment involves immediate discontinuation of the offending antibiotic if possible and starting specific antimicrobial therapy.
- For mild to moderate cases, oral metronidazole 500 mg three times daily for 10-14 days may be considered, but oral vancomycin is the preferred treatment for severe cases 1.
- In fulminant cases, a combination of intravenous metronidazole and oral vancomycin may be necessary.
- For recurrent infections, extended vancomycin tapers, fidaxomicin 200 mg twice daily for 10 days, or fecal microbiota transplantation may be considered 1.
Supportive Care
Supportive care includes:
- Fluid and electrolyte replacement
- Avoiding antimotility agents
- Infection control measures to prevent spread The pathophysiology involves C. difficile producing toxins A and B that damage the intestinal epithelium, leading to inflammation and pseudomembrane formation.
Complications
Early diagnosis and treatment are crucial to prevent complications such as:
- Toxic megacolon
- Perforation
- Sepsis Colectomy should be considered in cases of fulminant colitis, particularly in patients with perforation, systemic inflammation, and deteriorating clinical condition not responding to antibiotic therapy 1.
From the FDA Drug Label
14 CLINICAL STUDIES 14. 1 Diarrhea Associated with Clostridium difficile In two trials, Vancomycin Hydrochloride Capsules 125 mg orally four times daily for 10 days was evaluated in 266 adult subjects with C. difficile-associated diarrhea (CDAD)
CDAD was definite as ≥3 loose or watery bowel movements within the 24 hours preceding enrollment, and the presence of either C difficile toxin A or B, or pseudomembranes on endoscopy within the 72 hours preceding enrollment.
The diagnosis of Pseudomembranous (Clostridioides difficile-associated) colitis is based on the presence of:
- ≥3 loose or watery bowel movements within 24 hours
- C. difficile toxin A or B
- Pseudomembranes on endoscopy
The treatment for Pseudomembranous (Clostridioides difficile-associated) colitis is:
- Vancomycin Hydrochloride Capsules 125 mg orally four times daily for 10 days 2
- Fidaxomicin (DIFICID) tablets or oral suspension, dosage not specified in this context, but available in the label 3
From the Research
Diagnosis of Pseudomembranous Colitis
- The diagnosis of pseudomembranous colitis is typically made by endoscopic procedures, such as sigmoidoscopy or colonoscopy, which reveal the presence of pseudomembranes 4, 5, 6.
- Microbiological tests, including cycloserine cefoxitin fructose agar (CCFA) stool cultures and stool toxin assays, can also be used to confirm the diagnosis 4.
- The detection of Clostridium difficile or its toxin in stool samples is a key diagnostic criterion, with C. difficile or its toxin being cultured or isolated from the stools of 90% of patients with pseudomembranous colitis 6.
Treatment of Pseudomembranous Colitis
- Mild cases of pseudomembranous colitis may respond to discontinuation of the offending antibiotic and replacement of fluid and electrolytes 4, 7.
- Therapy with an anticlostridial antibiotic, such as oral vancomycin, metronidazole, or bacitracin, is often necessary for more severe cases 4, 7, 8, 6.
- A 10-day course of oral vancomycin is a commonly recommended treatment regimen 4, 8, although metronidazole and bacitracin may also be effective 7.
- Relapses are common, occurring in 5-50% of patients treated with these antibiotics 4, 7, and may require repeat courses of therapy or alternative treatments, such as fecal microbiota transplantation 5.
- Anion exchange resins and "biotherapy" (e.g., lactobacilli, Saccharomyces) have also been proposed as potential treatments for pseudomembranous colitis 4, 7.