Treatment and Monitoring

Stopping the inciting antibiotic is the most important step in the initial treatment of CDAD. If stopping antibiotic therapy is not effective or not practical, antimicrobial therapy directed specifically against C. difficile should be given for 10 days. Oral met-ronidazole (adult dosing: 500 mg three times daily or 250 mg four times daily; pediatric dosing: 30 mg/kg/day divided four times daily, not to exceed 4 g/day) and oral vancomycin (adult dosing: 125 mg four times daily; pediatric dosing: 40 mg/kg/day divided four times daily, not to exceed 2 g/day) have similar rates of efficacy, but met-ronidazole is considered the drug of choice for most cases because of cost and concerns regarding the emergence of vancomycin-resistant enterococcus (VRE). Rifaximin and nitazoxanide have demonstrated the potential for treatment of CDAD, although further study is recommended.

Severe disease occurs when patients with CDAD also have marked leukocytosis and/or new onset renal insufficiency. Severe complicated disease is defined as severe disease plus the presence of colitis complications, such as sepsis, volume depletion, electrolyte imbalance, hypotension, paralytic ileus, and toxic megacolon. Patients with signs of severe disease should receive oral vancomycin as initial therapy. Severe complicated disease should be treated with a combination of oral vancomycin and intravenous metronidazole. Surgical intervention may be indicated and lifesaving, particularly in cases complicated by toxic megacolon or colonic perforation.

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