What are the treatment guidelines for bacterial colitis?

From the Guidelines

Treatment of bacterial colitis should be guided by the most recent and highest quality evidence, with a focus on reducing morbidity, mortality, and improving quality of life. For Clostridioides difficile colitis, the most recent guidelines from 2019 1 suggest that first-line treatment for mild to moderate cases is oral vancomycin 125 mg four times daily for 10-14 days, as it has been shown to be more effective than metronidazole in some cases.

• For severe C. difficile infection, oral vancomycin 125 mg four times daily for 10-14 days is recommended, with the option to add intravenous metronidazole in fulminant cases.
• For recurrent C. difficile infections, fidaxomicin 200 mg twice daily for 10 days or vancomycin in a tapered and pulsed regimen may be used.
• The use of antibiotics such as metronidazole, vancomycin, and fidaxomicin should be guided by local resistance patterns and patient-specific factors like allergies and comorbidities.
• Supportive care, including adequate hydration, electrolyte replacement, and probiotics to restore gut flora, is essential during treatment.
• Avoiding anti-motility agents is important as they can worsen certain bacterial colitis by delaying toxin clearance.
• Treatment should be initiated promptly after diagnosis to prevent complications such as toxic megacolon or perforation. The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidelines from 2009 1 also provide recommendations for the treatment of Clostridium difficile infection, but the more recent guidelines from 2019 1 should be prioritized. Additionally, the AGA clinical practice guidelines on the management of mild-to-moderate ulcerative colitis from 2019 1 provide recommendations for the treatment of ulcerative colitis, but are not directly applicable to the treatment of bacterial colitis.

From the FDA Drug Label

Vancomycin Hydrochloride Capsules are indicated for the treatment of C. difficile-associated diarrhea. Vancomycin Hydrochloride Capsules are also used for the treatment of enterocolitis caused by Staphylococcus aureus (including methicillin-resistant strains) in adult and pediatric patients less than 18 years of age To reduce the development of drug-resistant bacteria and maintain the effectiveness of Vancomycin Hydrochloride Capsules and other antibacterial drugs, Vancomycin Hydrochloride Capsules should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria Staphylococcal enterocolitis: Total daily dosage is 500 mg to 2 g administered orally in 3 or 4 divided doses for 7 to 10 days.

The treatment guidelines for bacterial colitis using vancomycin are as follows:

• Indication: Vancomycin Hydrochloride Capsules are used for the treatment of enterocolitis caused by Staphylococcus aureus.
• Dosage: The total daily dosage for staphylococcal enterocolitis is 500 mg to 2 g administered orally in 3 or 4 divided doses for 7 to 10 days.
• Key consideration: Vancomycin Hydrochloride Capsules should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria 2.

From the Research

Treatment Guidelines for Bacterial Colitis

• The European and American Infectious Diseases Societies published new guidelines for the treatment of Clostridiodes difficile colitis in 2021, recommending fidaxomicin as the first line of treatment and vancomycin as a second choice 3.
• Metronidazole is recommended only in cases where other treatments are not available, although the Swiss Infectious Diseases Society still proposes metronidazole as first-line treatment 3.
• For empiric treatment of febrile dysenteric diarrhea, invasive bacterial enteropathogens (Shigella, Salmonella, and Campylobacter) should be suspected and adults may be treated empirically with 1000mg azithromycin in a single dose 4.
• Fidaxomicin is superior to metronidazole, vancomycin, or their combination for a sustained clinical response and in the prevention of recurrent CDI in the initial episode, first recurrence, and non-severe cases 5.

Antibiotic Treatment Options

• Metronidazole is suitable for the treatment of mild forms of CDI, which are essentially self-limiting 6.
• Vancomycin kills clostridia reliably, but the treatment is encumbered with a considerable risk of recurrence, which can be decreased by shortening the treatment to seven days and then switching to a (pulse, taper, chaser) regimen or by active restoration of the intestinal ecosystem (fecal transplant) 6.
• Fidaxomicin works faster than vancomycin and is associated with a lower risk of recurrence, making it a profitable option for patients with impending ileus or those whose medical condition does not allow prolonged treatment 6.
• Rifaximin does not have a clear place in the treatment of CDI due to a lack of compelling data on its efficacy and the risk of resistance 6.
• Tigecycline is a promising antibiotic for parenteral use, potentially more effective than intravenous metronidazole 6.

Treatment of Severe CDI

• In the oral treatment of severe CDI, fidaxomicin has a similar treatment outcome to vancomycin, and none of the antibiotic treatments are superior in the prevention of recurrent CDI 5.
• Fidaxomicin, vancomycin, or a combination of metronidazole and vancomycin have similar outcomes for sustained clinical response and prevention of recurrent CDI in patients with multiple recurrences 5.