| Nonspecific measures: discontinue implicated antibiotic; if continued antibiotic treatment is necessary, use an alternative agent to the one responsible for inducing C. difficile and avoid the use of fluoroquinolones and cephalosporins |
| Provide supportive measures |
| Avoid antiperistaltic agents and agents that reduce gastric acid |
| Vancomycin: 125 mg PO QID × 10–14 days or |
| Metronidazole: 500 mg PO 500 mg TID or 250 mg QID for 10 days or |
| Fidaxomicin: 200 mg PO BID × 10 days |
| Severe disease: vancomycin 500 mg PO QID plus metronidazole 500 mg IV q8h |
Relapses of CDI occur only with antibiotic treatment. The usual presentation is recurrence of the initial symptoms, usually at 3 to 10 days after discontinuation of metronidazole, vancomycin, or fidaxomicin. Patients generally respond to readministration of either agent, but up to 50% of patients will have another bout of CDI. This rate is cut in half by use of fidaxomicin, presumably because it has less impact on the normal colonic flora which is ultimately the source of this disease (Table 51.2).
Table 51.2 Management of relapsing Clostridium difficile diarrhea or colitis
| Metronidazole or vancomycin PO × 10 days for the first relapse; an alternative is fidaxomicin 200 mg PO BID × 7 days |
| For subsequent relapses: vancomycin 125 mg PO × 10 days followed by vancomycin 125 mg PO BID × 1 week then 125 mg QD × 1 week and then 125 mg QOD × 4–6 weeks |
