Updates in the Management of Clostridium Difficile for Adults

Kimberly E. Ng, PharmD, BCPS

US Pharmacist. 2019;44(4):HS9-HS12.

Vancomycin

Vancomycin is a glycopeptide that inhibits bacterial cell wall synthesis by blocking glycopeptide polymerization through binding to the d-alanyl-d-alanine portion of the cell-wall precursor. Vancomycin is administered orally for treatment of CDI and is minimally systemically absorbed to achieve higher concentrations in the colon. Adverse effects of oral vancomycin include abdominal pain, dysgeusia, nausea, headache, flatulence, and peripheral edema.^[6,7]

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Table 1. Recommendations for the Treatment of *Clostridium difficile* Infection in Adults
Clinical Definition	Supportive Clinical Data	Recommended Treatment
Initial episode, nonsevere	Leukocytosis with a white blood cell count of <15,000 cells/mL and a serum creatinine level <1.5 mg/dL	Vancomycin 125 mg given 4 times daily for 10 days, OR Fidaxomicin 200 mg given twice daily for 10 days Alternate if above agents are unavailable: metronidazole 500 mg 3 times per day by mouth for 10 days
Initial episode, severe	Leukocytosis with a white blood cell count of ≥15,000 cells/mL and a serum creatinine level >1.5 mg/dL	Vancomycin 125 mg 4 times per day by mouth for 10 days, OR Fidaxomicin 200 mg given twice daily for 10 days
Initial episode, fulminant	Hypotension or shock, ileus, megacolon	Vancomycin 500 mg 4 times per day by mouth or nasogastric tube. If ileus, consider adding rectal instillation of vancomycin. IV metronidazole 500 mg every 8 hours should be administered together with oral or rectal vancomycin, particularly if ileus is present.
First recurrence		Vancomycin 125 mg given 4 times daily for 10 days if metronidazole was used for the initial episode, OR Use a prolonged tapered and pulsed vancomycin regimen if a standard regimen was used for the initial episode (e.g.,125 mg 4 times per day for 10–14 days; then 2 times per day for a week; then once per day for a week; and then every 2 or 3 days for 2–8 weeks) OR Fidaxomicin 200 mg given twice daily for 10 days if vancomycin was used for the initial episode
Second or subsequent recurrence		Vancomycin in a tapered and pulsed regimen, OR Vancomycin 125 mg 4 times per day by mouth for 10 days followed by rifaximin 400 mg 3 times daily for 20 days, OR Fidaxomicin 200 mg given twice daily for 10 days, OR Fecal microbiota transplantation