Can I give Zofran (ondansetron) to a patient with Clostridioides difficile (C. difficile) infection?

Using Ondansetron (Zofran) in Patients with C. difficile Infection

Ondansetron (Zofran) should be avoided in patients with C. difficile infection as it may mask symptoms and potentially worsen outcomes by delaying appropriate diagnosis and treatment. 1

Rationale for Avoiding Ondansetron in C. difficile Infection

• Antiemetic agents with antimotility effects can lead to prolonged retention of C. difficile toxins in the colon, potentially worsening the infection and increasing risk of complications 1
• Masking diarrhea symptoms with agents like ondansetron can delay appropriate diagnosis and treatment monitoring of C. difficile infection 1
• Symptom suppression may create a false impression of clinical improvement while allowing the underlying infection to progress 1
• Antimotility agents have been associated with prolonged symptoms and increased complications in infectious diarrhea 1

Recommended Management for C. difficile Infection

First-Line Treatment

• For non-severe C. difficile infection: Oral vancomycin 125 mg four times daily for 10 days is now preferred over metronidazole 2, 3
• For severe C. difficile infection: Oral vancomycin 125 mg four times daily or fidaxomicin 200 mg twice daily for 10 days 2, 4
• For patients who cannot take oral medications: Vancomycin may be administered as a retention enema via a rectal tube 2

Supportive Care Without Ondansetron

• Provide intravenous fluid resuscitation to correct volume depletion 5
• Correct electrolyte imbalances promptly 5
• Consider albumin supplementation in patients with severe hypoalbuminemia 5
• Discontinue the inciting antibiotic agent(s) if possible 5, 3

Special Considerations

Disease Monitoring

• Diarrhea is a key clinical symptom for monitoring treatment response in C. difficile infection; suppressing this symptom can make it difficult to assess clinical improvement 1
• Severe C. difficile infection can progress to toxic megacolon, sepsis, or death if not properly managed 6

High-Risk Populations

• In patients with inflammatory bowel disease and C. difficile, antimotility agents pose an even greater risk due to already compromised colonic function 2, 1
• Immunocompromised patients are at higher risk for severe C. difficile infection and should especially avoid medications that may mask symptoms 1, 5
• Elderly patients have higher mortality rates from C. difficile infection and may present atypically, making symptom masking particularly dangerous 5

Alternative Approaches for Symptom Management

• Focus on treating the underlying C. difficile infection with appropriate antibiotics rather than symptom suppression 2, 3
• Provide adequate hydration and electrolyte replacement to manage symptoms associated with diarrhea 5
• For patients with legitimate antiemetic needs, consult with infectious disease specialists before considering any antiemetic agents 1

Infection Control Measures

• Implement strict handwashing with soap and water, as alcohol does not inactivate C. difficile spores 5
• Institute isolation precautions at first suspicion of C. difficile infection 5
• Practice good antibiotic stewardship to decrease rates of C. difficile infection 3