Expected Response to C. difficile Treatment
Yes, having one loose stool and one formed stool during treatment is an expected and encouraging sign of clinical response to therapy. 1
Understanding Treatment Response Timeline
Treatment response should be evaluated after at least 3 days, as clinical improvement may take 3-5 days, particularly with metronidazole. 1 The European Society of Clinical Microbiology and Infectious Diseases specifically notes that treatment response is present when stool frequency decreases or stool consistency improves, and this should be observed daily. 1
Normal Recovery Pattern
- The median time to resolution of diarrhea is 4-5 days with vancomycin treatment. 2
- Abdominal pain and fever typically resolve within 2-3 days of starting therapy. 3
- After clinical response begins, it may take weeks for stool consistency and frequency to become entirely normal. 1
Critical Monitoring Points
Watch for signs of clinical deterioration rather than expecting immediate complete resolution: 1
- Ensure stool frequency is decreasing (not increasing)
- Verify no new signs of severe disease are developing (WBC >15,000/mL, creatinine >1.5 mg/dL, fever >38.5°C) 1
- Confirm abdominal pain is improving, not worsening 1
Important Caveats
Do not perform a "test of cure" after treatment completion. 4 PCR testing can remain positive for weeks despite clinical resolution, and testing asymptomatic patients is not recommended. 4
The combination of vancomycin, fidaxomicin (Dificid), and metronidazole is unusual. 1 Standard guidelines recommend monotherapy with either vancomycin 125 mg four times daily, fidaxomicin 200 mg twice daily, or metronidazole 500 mg three times daily for 10 days—not combination therapy. 1 Using multiple agents simultaneously is not evidence-based and may indicate either treatment failure requiring regimen change or an error in prescribing.
If this represents a second treatment course (recurrence), the patient should receive either a vancomycin tapered-and-pulsed regimen or proceed directly to fecal microbiota-based therapy, which achieves 87-92% clinical resolution compared to 40-50% with additional antibiotic courses. 4, 5