Clostridium difficile treatment doesn’t have to be difficult! New treatment practice guidelines from the Association of Medical Microbiology and Infectious Disease Canada were released in 2018 with simplified recommendations.
C. difficile is now the most common hospital-acquired infection in Canada and contributes substantially to the morbidity and mortality of patients, in addition to increasing health care costs.
Previous, longstanding first-line treatment for an initial episode of mild to moderate C.difficile infection in an adult population was oral metronidazole, with oral vancomycin being a second-line for those who failed initial treatment or had a more severe episode. Recent studies have shown vancomycin’s superiority over metronidazole with improved cure rates and fewer reported side effects, leading Canadian experts to revise practice guidelines.
Current recommendations are as follows:
Initial or Recurrent mild-moderate episode (WBC <15, serum creatinine < 1.5x baseline) —> Vancomycin 125mg PO QID x 10-14 days
Severe, complicated (hypotensive shock, mega colon, ileus) —> Vancomycin 125mg PO QID PO or via NG PLUS Metronidazole IV 500mg Q8h
Second-line treatment still includes metronidazole and fidaxomicin, but the latter is associated with significant cost and barriers to access in some communities.
There is a lack of evidence in the pediatric population regarding the comparative effectiveness of vancomycin versus metronidazole for initial, uncomplicated episodes, therefore both remain first line options in these cases. This guideline also recommends against testing for C.difficile in children with diarrhea under 12 months of age due to high rates of asymptomatic colonization in this population.
2018, Official J Assoc Med Micro Inf Dis Canada 3.2; 2018 Clin Inf Disease