Should a patient with laboratory-confirmed Clostridium difficile (C. diff) infection, who is afebrile and stable, continue with conservative measures or initiate treatment with oral vancomycin?

Treatment of Laboratory-Confirmed Clostridium difficile Infection in a Stable Patient

Oral vancomycin 125 mg four times daily for 10 days should be initiated for this patient with laboratory-confirmed Clostridium difficile infection, despite current use of probiotics and loperamide. 1

Disease Assessment and Initial Management

• This 55-year-old woman has laboratory-confirmed C. difficile infection that has persisted for 10 days despite conservative management with probiotics and loperamide 1
• Although the patient is afebrile and not acutely ill, laboratory confirmation of C. difficile warrants appropriate antimicrobial therapy rather than continued conservative management 1
• Discontinuation of loperamide is strongly recommended as antimotility agents may worsen outcomes in C. difficile infection 2

Treatment Recommendations Based on Current Guidelines

• The 2017 IDSA/SHEA guidelines strongly recommend oral vancomycin 125 mg four times daily for 10 days for initial episodes of C. difficile infection, regardless of severity 1
• Vancomycin has demonstrated superior clinical cure rates (81.1%) compared to metronidazole (72.7%) in randomized controlled trials 1
• FDA-approved clinical trials showed clinical success rates of 81.3% and 80.8% for vancomycin 125 mg four times daily for 10 days in treating C. difficile infection 3

Rationale for Choosing Vancomycin Over Conservative Management

• Despite the patient being clinically stable, laboratory-confirmed C. difficile infection requires appropriate antimicrobial therapy to:

  • Prevent progression to severe disease 1
  • Reduce the risk of complications and transmission 1
  • Achieve faster resolution of symptoms compared to conservative management 3

• The median time to resolution of diarrhea with vancomycin treatment is 4-5 days according to clinical trials 3

• Continuing conservative management with probiotics alone is not recommended by guidelines for laboratory-confirmed C. difficile infection 1, 2

Important Considerations for Treatment

• Discontinue loperamide immediately as antimotility agents can mask symptoms and potentially worsen outcomes 2
• The standard 125 mg four times daily dose of vancomycin is sufficient; higher doses (250 mg or 500 mg) have not shown improved outcomes for non-severe cases 4, 5
• Oral vancomycin achieves fecal concentrations that are approximately 3 orders of magnitude higher than the MIC90 against C. difficile, even in patients with increased stool frequency 4

Monitoring and Follow-up

• Monitor for resolution of diarrhea, which typically occurs within 4-5 days of starting vancomycin 3
• Complete the full 10-day course of vancomycin even if symptoms resolve earlier 1
• Be aware that recurrence can occur in approximately 20% of patients after successful treatment 3, 6

Common Pitfalls to Avoid

• Continuing antimotility agents like loperamide during active C. difficile infection can mask symptoms and potentially worsen outcomes 2
• Relying solely on probiotics for treatment of laboratory-confirmed C. difficile infection is insufficient according to guidelines 1
• Delaying appropriate antimicrobial therapy in laboratory-confirmed cases may lead to prolonged symptoms and increased risk of complications 1