How should I treat a patient with Clostridioides difficile (C. diff) infection and an ileus?

Treatment of C. difficile Infection with Ileus

For patients with C. difficile infection (CDI) and ileus, treatment should include vancomycin 500 mg orally four times daily plus intravenous metronidazole 500 mg every 8 hours, with the addition of rectal vancomycin 500 mg in 100 mL normal saline every 6 hours as a retention enema if ileus is severe. 1

Initial Assessment and Management

• Patients with CDI and ileus represent a fulminant form of the disease, characterized by severely disturbed bowel function that may progress to toxic megacolon, shock, and high mortality 1
• Early detection of shock and aggressive management of underlying organ dysfunction are essential for improved outcomes 1
• Supportive measures should include:
  • Intravenous fluid resuscitation 1
  • Electrolyte replacement 1
  • Albumin supplementation in patients with severe hypoalbuminemia (<2 g/dL) 1
  • Monitoring of intra-abdominal pressure when risk factors for abdominal compartment syndrome are present 1

Antibiotic Treatment

Primary Therapy

• For fulminant CDI with ileus:

  • Vancomycin 500 mg orally four times daily for 10-14 days 1
  • Intravenous metronidazole 500 mg every 8 hours concurrently 1
  • Add rectal vancomycin 500 mg in approximately 100 mL normal saline every 6 hours as a retention enema, particularly if ileus is severe 1

• Rationale for this combination:

  • Ileus may impair delivery of oral vancomycin to the colon 1
  • IV metronidazole achieves therapeutic concentrations in inflamed colonic tissue 1
  • Rectal vancomycin provides direct delivery of the drug to the affected area 1

Important Considerations

• Discontinue the inciting antibiotic if possible 1
• If continued antibiotic therapy is required for another infection, choose agents less frequently implicated with CDI (aminoglycosides, sulfonamides, macrolides, tetracyclines) 1
• Consider discontinuing proton pump inhibitors if not clearly indicated 1
• Monitor vancomycin serum levels in patients with renal failure or prolonged high-dose therapy due to risk of systemic absorption through inflamed intestinal mucosa 1

Surgical Considerations

• Early surgical consultation is essential for patients with fulminant CDI and ileus 1

• Indicators for possible surgical intervention include:

  • Rising WBC count (≥25,000) 1
  • Rising lactate level (≥5 mmol/L) 1
  • Progressive organ failure 1
  • Worsening abdominal distension 1

• Surgical options include:

  • Subtotal colectomy with end ileostomy (traditional approach) 1
  • Diverting loop ileostomy with colonic lavage (newer alternative that may improve outcomes) 1

Alternative and Adjunctive Therapies

• For patients not responding to standard therapy, consider:
  • Intravenous tigecycline (loading dose 100 mg followed by 50 mg twice daily) 1
  • Intravenous immunoglobulins (150-400 mg/kg) 1
  • Bezlotoxumab (human monoclonal antibody against C. difficile toxin B) may be considered for patients at high risk for recurrence, though data in fulminant disease is limited 1

Prevention of Recurrence

• After resolution of the acute episode, consider:
  • Extended pulsed vancomycin regimen for patients at high risk of recurrence 1
  • Fidaxomicin (200 mg twice daily for 10 days) for patients at high risk of recurrence 1, 2
  • Fecal microbiota transplantation for patients with multiple recurrences who have failed appropriate antibiotic treatments 1

Monitoring and Follow-up

• Monitor for clinical improvement (typically within 3-5 days):

  • Decreased abdominal distension 1
  • Resolution of ileus 1
  • Normalization of WBC count and lactate levels 1
  • Improvement in vital signs 1

• If no improvement or clinical deterioration occurs:

  • Reassess need for surgical intervention 1
  • Consider alternative diagnoses or complications 1

Common Pitfalls and Caveats

• Relying solely on oral antibiotics in patients with ileus may result in treatment failure due to impaired drug delivery 1
• Failure to recognize progression to fulminant disease can lead to delayed surgical intervention and increased mortality 1
• Intravenous vancomycin is ineffective for CDI as it is not excreted into the colon 1
• Testing perirectal swabs for C. difficile may be necessary when stool specimens cannot be obtained due to ileus 1
• Continued use of broad-spectrum antibiotics significantly increases the risk of CDI recurrence 1