Severe, complicated or fulminant C. difficile infection in adults

For the approach to managing severe, complicated or fulminant C. difficile infection, see Severe, complicated or fulminant Clostridioides difficile infection.

Note: Do not give vancomycin intravenously to treat C. difficile infection.

For severe C. difficile infection in adults, use:

vancomycin 125 mg orally or enterally, 6-hourly for 10 days¹ ² ³. vancomycin vancomycin vancomycin

In adults with severe complicated C. difficile infection (eg hypotension or shock, ileus, toxic megacolon) or fulminant disease (rapidly progressing severe disease), useEreshefsky 2021 Gonzales, 2010 Johnson, 2021:

vancomycin 250 mg or 500 mg orally or enterally, 6-hourly for 10 days¹ ² ³ vancomycin vancomycin vancomycin

PLUS

metronidazole 500 mg intravenously, 8-hourly for 10 days. metronidazole metronidazole metronidazole

Consider adding intracolonic vancomycin to the regimens above, particularly in the presence of ileus. Use:

vancomycin 500 mg in 100 mL sodium chloride 0.9% rectally (via rectal tube), administered as a retention enema, 6-hourly⁴ ⁵. vancomycin vancomycin vancomycin

For adults whose clinical condition fails to improve on the regimens above, seek expert advice.

For information about follow-up testing and patient education, see Follow-up for patients with Clostridioides difficile infection.

¹ Injectable vancomycin can be given orally or enterally, as an alternative to oral capsules. Dissolve 500 mg of vancomycin powder in 10 mL of water, measure the appropriate dose (eg 125 mg = 2.5 mL), and give orally or enterally. Flavouring syrups can be added before administration to improve palatability.Return

² Intravenous vancomycin is not effective against C. difficile infection because of inadequate penetration of the drug into the lumen of the colon.Return

³ Systemic absorption of vancomycin can occur with oral or enteral administration. If toxicity is suspected, consider measuring vancomycin plasma concentrations; otherwise, therapeutic drug monitoring is not required.Return

⁴ Use vancomycin drawn from an injectable vial to prepare the retention enema.Return

⁵ The optimal administration of intracolonic vancomycin has not been established in clinical trials, but case series describe various methods that involve retaining vancomycin in the colon for a period of time after installation (eg 60 minutes, 3 hours)Apisarnthanarak, 2002 Shetler, 2001.Return