From the Guidelines
Oral antibiotics are not recommended for the treatment of extraintestinal Clostridioides difficile infections, as they are unlikely to achieve adequate tissue concentrations at the site of infection. For extraintestinal C. difficile infections, such as bacteremia, abscesses, or wound infections, intravenous antibiotics are typically required rather than oral options. According to the 2021 clinical practice guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 1, the recommended treatment for fulminant CDI, which may involve extraintestinal infection, includes vancomycin 500 mg 4 times daily by mouth or by nasogastric tube, and intravenously administered metronidazole (500 mg every 8 hours) should be administered together with oral or rectal vancomycin, particularly if ileus is present. Some key points to consider in the treatment of extraintestinal C. difficile infections include:
- The need for intravenous antibiotics to achieve adequate tissue concentrations at the site of infection
- The importance of surgical drainage or debridement as an adjunct to antibiotic therapy for localized extraintestinal infections
- The potential for extended treatment duration, typically ranging from 10-14 days, but may be extended based on clinical response and the specific site of infection
- The consideration of combination therapy with other antibiotics depending on the site of infection, as C. difficile is an anaerobic bacterium that can cause severe infections outside the intestinal tract. It is essential to note that these extraintestinal infections typically occur in immunocompromised patients or following abdominal surgery or trauma, and the treatment approach should be individualized based on the patient's specific clinical presentation and underlying risk factors, as outlined in the guideline by 1.
From the Research
Effective Oral Antibiotics for Extraintestinal Infection due to Clostridioides difficile
- Vancomycin is considered effective for the treatment of Clostridioides difficile infection (CDI) 2, 3, 4, 5
- Fidaxomicin is also recommended for first-line therapy for most cases of CDI 2, 3, 5
- Metronidazole may be used for mild-to-moderate disease in younger patients who have no or only few risk factors for recurrence 2, 3
- Bezlotoxumab infusion may be considered as an adjunctive therapeutic strategy in addition to standard care for patients with several risk factors for recurrence 2, 3
Considerations for Extraintestinal Infections
- Extraintestinal CDIs occur mainly in hospitalized patients with significant comorbidities 6
- These infections may result from intestinal perforation, intestinal surgery, colonization by feces, or bacteremia 6
- The choice of antibiotic should be based on the severity of the infection, the presence of comorbidities, and the risk of recurrence 2, 3, 5
Antibiotic Resistance and Efficacy
- Vancomycin and fidaxomicin have been shown to be effective in treating CDI, with vancomycin being superior in severe cases 4
- Metronidazole has been associated with lower rates of treatment success compared to vancomycin and fidaxomicin 3, 5
- Resistance profiles for C. difficile have been reported, with 4.07% resistance to vancomycin and 3.49% resistance to metronidazole in one study 5