What is the recommended treatment for mild Clostridioides difficile (C. diff) infection?

Treatment of Mild Clostridioides difficile Infection

For mild Clostridioides difficile infection (CDI), oral vancomycin 125 mg four times daily for 10 days or oral fidaxomicin 200 mg twice daily for 10 days is recommended as first-line therapy. 1, 2

Disease Severity Assessment

Before initiating treatment, it's crucial to assess disease severity:

• Mild-to-moderate CDI is defined by:
  • Leukocytosis with WBC ≤15,000 cells/mL 1
  • Serum creatinine <1.5 mg/dL 1
  • Stool frequency <4 times daily 2
  • No signs of severe colitis 2

First-Line Treatment Options

Recommended Treatment:

• Oral vancomycin 125 mg four times daily for 10 days 1, 3
• OR Oral fidaxomicin 200 mg twice daily for 10 days 1, 4

Alternative Treatment:

• Oral metronidazole 500 mg three times daily for 10 days may be considered in settings where access to vancomycin or fidaxomicin is limited 5, 2
• However, metronidazole should be limited to initial episodes of mild-moderate CDI due to increasing treatment failures 5

Important Clinical Considerations

• Discontinue the inciting antibiotic agent(s) as soon as possible to reduce the risk of CDI recurrence 1
• Avoid antimotility agents such as loperamide and opiates, especially in the acute setting 1
• Repeated or prolonged courses of metronidazole should be avoided due to risk of cumulative and potentially irreversible neurotoxicity 5
• Recent evidence shows lower clinical success rates for metronidazole compared to vancomycin, making vancomycin preferable even for mild-moderate CDI 5

Treatment Selection Factors

• Factors associated with metronidazole failures include:

  • Age > 60 years 5
  • Fever 5
  • Hypoalbuminemia 5
  • Peripheral leukocytosis 5
  • ICU stay 5
  • Abnormal abdominal CT imaging 5

• Patients receiving metronidazole have a longer time to symptomatic improvement than patients receiving vancomycin 5

Monitoring Response

• Monitor for clinical response (decreased stool frequency, improved consistency) within 3 days of treatment 2
• No follow-up stool testing is needed if symptoms resolve 2
• Watch for signs of treatment failure (absence of improvement after 3-5 days) 2

Treatment of Recurrence

• For first recurrence of mild-moderate CDI, oral metronidazole or vancomycin is recommended 5
• For subsequent recurrences, vancomycin is the recommended therapy, often with pulsed or tapering courses 5

Common Pitfalls to Avoid

• Failing to assess disease severity before selecting treatment 1
• Continuing the inciting antibiotic when it could be discontinued 1
• Using metronidazole for prolonged courses due to neurotoxicity risk 5
• Using oral vancomycin for infections other than CDI (not effective for systemic infections) 3
• Failing to recognize treatment failure and delay alternative therapy 2