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Clostridium difficile Colitis

I. Purpose

Clostridium difficile infection (CDI) is an increasingly common cause of nosocomial morbidity and mortality from the gram-positive, spore-forming anaerobic bacillus. Up to 30% of patients with fulminant CDI require urgent surgery, and there is a >40% mortality rate in those requiring emergency surgery. Prompt recognition and treatment are therefore paramount.

II. Guideline

A. Initial Evaluation

  • Clinical suspicion for CDI

    • Recent healthcare facility exposure
    • Recent antibiotic use (especially clindamycin)

    • 3 unformed stools in 24 hours without laxatives

    • Consider tube feeds as a cause of diarrhea if applicable

  • Labs

    • CBC
    • BMP
    • C. difficile PCR with Reflex Toxin Panel
      • PCR negative → C. difficile not present
      • PCR positive/Toxin positive → Treat
      • PCR positive/Toxin negative → Likely colonized, treatment based on clinical picture:
        • Does the patient have >3 risk factors?
        • Have alternative causes of diarrhea been ruled out?
        • Are symptoms/WBC/vitals worsening off therapy?

  • Imaging

    • Consider CT Abdomen/Pelvis with IV contrast for suspected severe or fulminant CDI

  • Evaluation of Severity

    • Nonsevere CDI

      • HR < 90 bpm, SBP > 100 mmHg
      • Tmax < 101.5°F
      • WBC < 15,000
      • Normal lactate
      • Oliguria responsive to fluids
      • Mild abdominal tenderness

    • Severe CDI

      • HR > 90 bpm without hypotension
      • Fever > 101.5°F
      • WBC > 15,000
      • Creatinine > 1.5 mg/dL
      • Moderate abdominal tenderness

    • Fulminant CDI

      • Shock with hypotension
      • Need for vasopressors
      • Ventilator dependence
      • Oliguria unresponsive to fluids
      • Perforation
      • Toxic megacolon (cecal diameter >12 cm or colon diameter >6 cm)

B. Antibiotic Therapy

  • Nonsevere CDI

    • Vancomycin 125 mg PO q6h x 10 days
    • OR Fidaxomicin 200 mg PO BID x 10 days (for high-risk patients)

  • Severe CDI

    • Vancomycin 125 mg PO q6h x 10 days
    • OR Fidaxomicin 200 mg PO BID x 10 days (for high-risk patients)

  • Fulminant CDI

    • Vancomycin 500 mg PO q6h PLUS Metronidazole 500 mg IV q8h
    • If ileus (no megacolon): Add Vancomycin 500 mg PR q6h

  • Recurrent CDI

    • First recurrence: Fidaxomicin 200 mg PO BID x 10 days
    • Multiple recurrences:
      • Infectious Disease (ID) consult
      • Fidaxomicin 200 mg PO BID x 10 days
      • Vancomycin taper
      • Vancomycin followed by Rifaximin

  • High-risk features (≥3 of the following):

    • Recent high-risk antibiotics (fluoroquinolones, clindamycin, carbapenems, 3rd/4th gen cephalosporins)
    • Healthcare exposure (past 12 weeks)
    • Age > 65
    • Chronic gastric acid suppression
    • Solid organ transplant
    • Hematopoietic stem cell transplant
    • Chemotherapy
    • CKD or ESRD
    • Prolonged hospitalization
    • Recent GI procedure

  • Fidaxomicin limitations

    • Do not use if PCR+/Toxin-
    • Requires ID attending approval (page 317-4376)
    • Confirm affordability prior to discharge

C. Indications for Surgical Management

  • Key principle: Preoperative physiologic status is the strongest predictor of postoperative mortality

  • Strongly consider TAC with end ileostomy (TAC/EI) if:

    • Severe colonic distension
    • Clinical deterioration despite maximal medical therapy (within 24–48h)
    • Pneumatosis
    • Impending perforation

D. Postoperative Management of TAC/EI

  • Consider pelvic drain (based on rectal stump quality)
  • ICU admission strongly recommended

  • Antibiotic therapy post-op

    • No clear guidelines exist
    • If perforation: consider 4-day course of abdominal sepsis antibiotics
    • Continue Vancomycin 500 mg PO q6h or Metronidazole 500 mg IV q8h x 7 days (until bowel function returns)

III. References

  1. McDonald LC, et al. Clin Infect Dis. 2018;66(7):e1–e48. doi:10.1093/cid/cix1085
  2. Johnson S, et al. Clin Infect Dis. 2021
  3. Cornely OA, et al. Lancet Infect Dis. 2012;12(4):281–289. doi:10.1016/S1473-3099(11)70374-7
  4. Van der Wilden G, et al. Surg Infect. 2015
  5. Seltman A. Clin Colon Rectal Surg. 2012
  6. Choron R, Lipsett P. In: Current Surgical Therapy, 13th Ed. 2020
  7. Kelly CR, et al. Am J Gastroenterol. 2021;116(6):1124–1147
  8. Vanderbilt Antimicrobial Stewardship Program. CDI Guidelines

IV. Authors

  • Michael J. Derickson, MD
  • Joshua J. Thompson, MD, PhD
  • Jade Flynn, PharmD, BCPS

July 22, 2024