What is the recommended treatment for a patient with severe Clostridioides difficile (C. difficile) infection, ileus, and hypotension?

Treatment of Severe Clostridioides difficile Infection with Ileus and Hypotension

For this critically ill 84-year-old patient with severe C. difficile infection complicated by ileus and hypotension, the recommended treatment is vancomycin 500 mg four times daily by nasogastric tube plus vancomycin rectally (via retention enema) along with intravenous metronidazole 500 mg three times daily for 10-14 days. 1, 2

Patient Assessment

This patient has several markers of severe, complicated C. difficile infection:

• Advanced age (84 years) - significant risk factor
• Hypotension (BP 80s/40s) requiring vasopressor support
• Ileus (confirmed on KUB X-ray)
• Severe diarrhea with limited oral intake for 3 days
• Positive C. difficile PCR test
• Requiring intubation for airway protection

Treatment Algorithm

First-Line Therapy for Severe CDI with Ileus

1. Dual-route vancomycin administration:

   • Vancomycin 500 mg four times daily via nasogastric tube 1
   • PLUS vancomycin 500 mg in 100 mL normal saline as retention enema every 4-12 hours 1

2. Adjunctive intravenous therapy:

   • Metronidazole 500 mg intravenously three times daily for 10-14 days 1, 2

3. Duration of therapy:

   • Continue for at least 10-14 days 1
   • May need to extend treatment based on clinical response

Rationale for Treatment Selection

The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines specifically recommend this combination therapy for severe CDI when oral therapy alone is compromised by ileus 1. The presence of ileus significantly impairs the delivery of oral antibiotics to the colon, necessitating both NG and rectal administration of vancomycin to ensure adequate drug concentrations throughout the colon.

IV metronidazole is added because it can achieve therapeutic concentrations in inflamed colonic tissue, providing additional coverage when intestinal absorption may be compromised 2, 3.

Why Other Options Are Less Optimal

• Vancomycin by NG tube alone: Insufficient for patients with ileus, as drug delivery to the distal colon will be impaired 1, 2

• Vancomycin plus oral metronidazole: Oral metronidazole would be ineffective in the setting of ileus; IV metronidazole is preferred 1, 3

• Vancomycin plus fidaxomicin plus bezlotoxumab: While fidaxomicin is now preferred for non-severe and some severe CDI cases, there is insufficient evidence for its use in fulminant CDI with ileus 2, 4. Additionally, bezlotoxumab (an anti-toxin antibody) is primarily indicated for prevention of recurrence rather than primary treatment of acute severe infection 2

Monitoring and Additional Management

• Closely monitor vital signs, particularly blood pressure and signs of shock
• Assess for clinical improvement (decreased abdominal pain, resolution of ileus)
• Monitor white blood cell count, lactate levels, and renal function
• Continue supportive care with IV fluids and vasopressors as needed
• Consider early surgical consultation if clinical deterioration occurs despite maximal medical therapy 2, 5

Important Considerations

• Surgical evaluation: This patient should be evaluated by surgery given the severity of illness. Serum lactate >5.0 mmol/L or clinical deterioration despite maximal therapy are indicators for potential surgical intervention 1, 5

• Antibiotic stewardship: Discontinue any unnecessary antibiotics that may have contributed to CDI 2, 6

• Infection control: Implement contact precautions with hand hygiene using soap and water (not alcohol-based hand sanitizers) 2

• Recurrence prevention: Once the acute episode resolves, assess risk factors for recurrence and consider strategies to prevent recurrent infection 2

This comprehensive approach addresses both the immediate severe infection while positioning the patient for the best possible outcome in terms of mortality reduction and quality of life preservation.