What is the best management plan for a 79-year-old female with recurrent Clostridium difficile infection, chronic kidney disease (CKD) stage 3, congestive heart failure (CHF), hypertension, Lewy body dementia, and multiple other comorbidities?

Management of Recurrent Clostridioides difficile Infection in a Frail Elderly Patient with Multiple Comorbidities

For this 79-year-old patient completing fidaxomicin therapy for her second episode of CDI, the priority is preventing a third recurrence through extended prophylaxis with oral vancomycin tapered-pulsed regimen, aggressive management of her multiple recurrence risk factors (age, CKD, CHF, PPI use, hypoalbuminemia), and consideration of fecal microbiota transplantation if she experiences another recurrence. 1

Immediate CDI Management (Current Episode)

Complete the current fidaxomicin course as ordered (through 11/13/25), as she is clinically responding with resolution of diarrhea and no systemic symptoms. 1

• Continue cholestyramine through 11/15/25 as ordered, though evidence for its efficacy in preventing recurrence is limited; it may bind residual toxins but should not interfere with ongoing fidaxomicin absorption given the timing. 1

• Continue Lactobacillus supplementation, recognizing that while Saccharomyces boulardii and Lactobacillus species show promise for CDI recurrence prevention, none has demonstrated significant and reproducible efficacy in controlled trials. 1

• Maintain strict contact/droplet isolation precautions with single-room isolation; reinforce handwashing with soap and water (not alcohol-based sanitizers, which do not inactivate C. difficile spores) for all staff and visitors. 2

Prevention of Third Recurrence (Critical Priority)

This patient is at extremely high risk for a third recurrence based on multiple factors: age >65 years, second recurrence, CKD stage 3, CHF, continued PPI use, hypoalbuminemia (albumin 3.9 g/dL is borderline), and frailty. 1, 3

Antibiotic Strategy After Fidaxomicin Completion

Initiate oral vancomycin tapered and pulsed regimen immediately after completing fidaxomicin (starting 11/14/25), as this is the IDSA/SHEA guideline-recommended approach for second or subsequent CDI recurrences. 1

• Specific vancomycin taper-pulse regimen: Vancomycin 125 mg four times daily for 10–14 days, then 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. 1

• Rationale: This extended regimen keeps C. difficile vegetative forms suppressed while allowing restoration of normal gut microbiota; fidaxomicin alone has shown less efficacy in patients with ≥2 recurrences. 1

• Alternative consideration: Vancomycin standard course followed by rifaximin 400 mg three times daily for 20 days showed trend toward reduced recurrence (15% vs 31%, P=0.11 in small RCT), though evidence is weaker than for tapered-pulse vancomycin. 1

Addressing Modifiable Risk Factors

Discontinue or minimize PPI therapy (currently on omeprazole), as continued PPI use is associated with increased CDI recurrence risk; consider step-down to H2-blocker or PRN antacid therapy if GERD symptoms are minimal. 1

• Reassess PPI necessity given her current lack of reflux symptoms and the known association between PPIs and recurrent CDI. 1

Optimize nutritional status and albumin levels, as hypoalbuminemia is associated with worse CDI outcomes and recurrence. 1

• Continue aggressive nutritional supplementation (Pro-Stat 30 mL BID, Ensure before meals, house supplement at bedtime) to maintain albumin >3.5 g/dL and prealbumin >20 mg/dL. 1

• Consider albumin supplementation if levels drop below 2 g/dL, both for supportive care and potential anti-toxin properties. 1

Avoid all non-essential antibiotics during and after CDI treatment, as antibiotic exposure is the strongest risk factor for CDI recurrence. 1

• If systemic antibiotics become necessary (e.g., for UTI, pneumonia), consider concurrent low-dose vancomycin prophylaxis (125 mg once daily) during and for 1 week after the antibiotic course, particularly given her history of multiple recurrences. 1

• Two retrospective studies showed decreased risk of subsequent CDI in patients with prior recurrent CDI who received empiric vancomycin during subsequent antibiotic exposure, though prospective data are lacking. 1

Plan for Potential Third Recurrence

If she develops a third recurrence despite tapered-pulse vancomycin, strongly recommend fecal microbiota transplantation (FMT), which has strong evidence (moderate quality) for patients with multiple recurrences who have failed appropriate antibiotic treatments. 1

• FMT efficacy: Success rates of 80–100% when administered via colonoscopy, with the first randomized trial showing marked superiority over vancomycin alone (cure rate 81% vs 31%, P<0.001). 1

• FDA-approved oral FMT option (Vowst) is now available as prophylactic therapy for recurrent CDI, though cost and insurance coverage may be barriers. 4

• Coordinate with gastroenterology/infectious diseases for FMT planning if third recurrence occurs. 1

Management of Comorbidities Affecting CDI Risk

Chronic Kidney Disease Stage 3

CKD increases both CDI risk and recurrence rates, with patients having higher mortality and healthcare costs. 3

• Current renal function (Cr 1.33 mg/dL, eGFR 40 mL/min/1.73m²) is stable; continue weekly BMP monitoring as ordered. 3

• Vancomycin dosing does not require adjustment for oral administration in CDI, as systemic absorption is minimal (<5%) and the drug acts locally in the GI tract. 1

• Avoid nephrotoxic agents and NSAIDs; ensure adequate hydration to prevent prerenal azotemia (current BUN/Cr ratio of 24 suggests mild prerenal component). 3

Congestive Heart Failure

Maintain euvolemic state to optimize gut perfusion and immune function; current exam shows no edema and lungs are clear. 1

• Continue furosemide Mon/Thu schedule with close monitoring of weights (weekly as ordered); adjust diuretics if volume status changes. 1

• Low-normal BP (104/57 today) may reflect overdiuresis or medication effect; monitor for orthostatic hypotension and consider holding chlorthalidone if SBP persistently <100 mmHg. 1

Hypothyroidism with Elevated TSH

Markedly elevated TSH (19.19 µIU/mL) indicates under-replacement, which may contribute to constipation, fatigue, and impaired immune function. 2

• Increase levothyroxine dose in consultation with PCP/endocrinology; typical adjustment is 12.5–25 mcg increase given age and cardiac history. 2

• Ensure proper levothyroxine administration on empty stomach, separated by ≥4 hours from calcium, iron, and multivitamins to optimize absorption. 2

• Recheck TSH in 6–8 weeks after dose adjustment. 2

Hyponatremia

Mild hyponatremia (Na 132 mmol/L) may worsen with aggressive diuresis or SIADH from multiple medications. 2

• Monitor sodium with weekly CMPs as ordered; consider earlier recheck if mental status changes or weakness worsens. 2

• Review diuretic regimen (chlorthalidone and furosemide) and consider reducing or holding chlorthalidone if sodium trends downward or BP remains low. 2

• Ensure adequate oral solute intake (protein, sodium in diet) and avoid hypotonic fluids. 2

Monitoring and Follow-Up

Strict monitoring for CDI recurrence is essential given her high-risk profile. 1, 2

• Nursing to document stool frequency and consistency each shift; notify provider immediately if ≥3 loose stools in 24 hours or any systemic symptoms (fever, abdominal pain, leukocytosis). 1, 2

• Do not perform "test of cure" after CDI treatment, as testing cannot distinguish colonization from active infection. 1

• Weekly labs (CBC, CMP, Mg, Phos) as ordered through 11/19/25 to monitor renal function, electrolytes, and WBC count. 2

• Continue PT/OT/ST 5x/week and 4x/week respectively to address debility and reduce fall risk, which is critical for maintaining independence and quality of life. 2

Infection Control and Isolation

Maintain single-room isolation with contact/droplet precautions until facility criteria for discontinuation are met (typically 48 hours after diarrhea resolution, though policies vary). 2

• Reinforce gown/glove use and handwashing with soap and water (not alcohol) for all staff and visitors entering room. 2

• Environmental cleaning with sporicidal agents (bleach-based) is essential to prevent transmission. 2

Medication Reconciliation for CDI Risk

Review all medications for CDI risk factors and anticholinergic burden:

• Oxybutynin ER: High anticholinergic burden may worsen cognition and constipation; consider discontinuation or switch to mirabegron if overactive bladder symptoms recur, as she is currently continent. 2

• Clonazepam: High fall and cognitive risk in elderly; consider gradual taper with psychiatry input if anxiety is controlled, given her pleasant mood and good sleep. 2

• Escitalopram: May contribute to hyponatremia; monitor sodium closely but continue if mood stable. 2

Goals of Care Alignment

DNR status is documented; ensure ongoing communication with patient/family about goals of care, particularly if third recurrence occurs or if FMT is being considered. 2

• Quality of life focus: Preventing recurrent CDI is critical to maintaining her functional status, avoiding rehospitalization, and supporting her ability to participate in rehabilitation. 2