What is the treatment for Clostridium difficile in elderly patients in the hospital?

Treatment of Clostridium difficile Infection in Elderly Hospitalized Patients

For elderly hospitalized patients with Clostridium difficile infection (CDI), oral vancomycin 125 mg four times daily for 10 days or fidaxomicin 200 mg twice daily for 10 days are the recommended first-line treatments, with vancomycin being preferred due to its established efficacy and lower cost. 1

Treatment Algorithm Based on Disease Severity

Initial Assessment

• Determine severity of infection:
  • Non-severe: No markers of severe disease
  • Severe: One or more of the following:
    • Marked leukocytosis (>15 × 10⁹/L)
    • Decreased blood albumin (<30 g/L)
    • Rise in serum creatinine (≥133 μM or ≥1.5 times premorbid level)
    • Advanced age with significant comorbidities

First-Line Treatment Options

1. Non-severe CDI:

   • Oral vancomycin 125 mg four times daily for 10 days 2, 1
   • Alternative: Fidaxomicin 200 mg twice daily for 10 days 1
   • Note: While metronidazole 500 mg three times daily for 10 days was historically used for mild-moderate cases 2, recent guidelines have shifted to preferring vancomycin or fidaxomicin due to superior efficacy 1

2. Severe CDI:

   • Oral vancomycin 125 mg four times daily for 10 days 2, 1
   • Alternative: Fidaxomicin 200 mg twice daily for 10 days 1

When Oral Therapy Is Not Possible

• Non-severe disease:

  • Intravenous metronidazole 500 mg three times daily for 10 days 2

• Severe disease:

  • Intravenous metronidazole 500 mg three times daily for 10 days PLUS
  • Vancomycin 500 mg in 100 mL normal saline four times daily via retention enema 2
  • AND/OR vancomycin 500 mg four times daily via nasogastric tube 2

Management of Recurrent CDI

Recurrence is common in elderly patients, occurring in up to 25% of cases 3.

First Recurrence

• Treat as a first episode based on severity assessment 2
• Consider fidaxomicin 200 mg twice daily for 10 days, which has shown lower recurrence rates (19.7%) compared to vancomycin (35.5%) 4

Second and Subsequent Recurrences

• Vancomycin 125 mg four times daily for 10 days, followed by a taper/pulse regimen 2, 1:
  • 125 mg twice daily for 7 days, then
  • 125 mg once daily for 7 days, then
  • 125 mg every 2-3 days for 2-8 weeks

Special Considerations for Elderly Patients

• Elderly patients have higher morbidity, mortality, and recurrence rates 1
• Advanced age is an independent risk factor for recurrence 1
• Monitor renal function during and after treatment with vancomycin, even in those with normal baseline function 5
• Elderly patients may take longer to respond to therapy compared to younger patients 5
• Do not discontinue treatment prematurely in elderly patients 5
• Consider prolonged vancomycin prophylaxis (125 mg once daily) for elderly patients with multiple recurrences who have failed or don't have access to fecal microbiota transplantation 6

Adjunctive Measures

• Discontinue the inciting antibiotic if possible 1
• Review and discontinue proton pump inhibitors if not medically necessary 1
• Implement strict infection control measures:
  • Patient isolation until 48 hours after diarrhea resolution
  • Hand hygiene with soap and water (alcohol-based sanitizers don't kill C. difficile spores)
  • Environmental cleaning with sporicidal agents

Surgical Consultation

Prompt surgical evaluation should be obtained for patients with:

• Perforation of the colon
• Systemic inflammation not responding to antibiotic therapy
• Toxic megacolon or severe ileus 2

Early surgical intervention can reduce mortality in severe cases 2.

Key Points for Elderly Patients

• Higher doses of vancomycin (500 mg four times daily) have not shown additional benefit over the standard dose (125 mg four times daily) 7
• Fidaxomicin may be particularly beneficial in preventing recurrence in elderly patients 1, 4
• Careful monitoring for adverse effects and treatment response is essential in this vulnerable population