Management of inflammatory bowel disease with Clostridium difficile infection

Table 4 Treatment of clostridium difficile infection in inflammatory bowel disease[3,4]

Severity	Criteria	Treatment	Comments
First episode
Stop all non-CDI related antibiotic therapy if possible
Mild to moderate disease	Diarrhea and symptoms not meeting criteria for severe disease	Metronidazole 500 mg by mouth 3 times per day for 10 d to 14 d	In hospitalized patients with UC and nonsevere CDI, treatment with a vancomycin-containing regimen vs metronidazole alone resulted in fewer readmissions and shorter LOS[70]
		or
		Vancomycin 125 mg by mouth 4 times per day for 10 to 14 d
Severe disease	Serum albumin < 3 g/dL AND one of the following:	Vancomycin 125 mg by mouth 4 times per day for 10 to 14 d
	WBC ≥ 15000 cells/mm3
	Abdominal tenderness
	Creatinine ≥ 133 μmol/L
Severe, complicated disease	Admission to intensive care unit	Vancomycin 500 mg by mouth or nasogastric tube 4 times per day	Consider early surgical consultation
	Hypotension ± vasopressor requirement	and
	Fever ≥ 38.5 °C	Metronidazole 500 mg IV every 8 h
	Ileus	and, if ileus,
	Mental status changes	Vancomycin 500 mg in 500 mL saline as enema 4 times per day
	WBC ≥ 35000 cells/mm3 or ≤ 2000 cells/mm3
	Serum lactate ≥ 2.2 mmol/L
	End organ failure
Recurrent CDI
First recurrence		Metronidazole 500 mg by mouth 3 times per day for 10 to 14 d
		or
		Vancomycin 125 mg by mouth 4 times per day for 10 to 14 d
		or
		Fidaxomicin 200 mg by mouth 2 times per day for 10 d
Second recurrence		-Tapered and pulsed vancomycin
		or
		Fidaxomicin 200 mg by mouth 2 times per day for 10 d
Subsequent recurrence		-Fecal microbiota transplant

LOS: Length of stay; CDI: Clostridium difficile infection; UC: Ulcerative colitis.