C Diff Treatment Changes

A few weeks ago, a post on Clay Smith’s Journal Feedabout the new IDSA C diff guidelines caught my attention (specifically, that metronidazole is no longer recommended as first line therapy). Whuut? I tweeted this and @medquestioningtweeted back, "Need to dig to see why they dropped metro in the bucket." Yes, @medquestioning, my thoughts exactly.   Mentioned in this episode ERcast 2.0launches May 1, 2018 To sign up for the new site and 1 year of free CME, click here Essentials of Emergency Medicineis just around the corner. If you can't make it to Vegas, the digital live stream is pretty sweet.     New IDSA C Diff Guideline Treatment Recommendations   Initial Episode, Non Severe (WBC ≤ 15k, creatinine < 1.5) First Line Vancomycin 125 mg PO QID for 10 days Fidaxomicin 200mg PO  BID for 10 days Second line Metronidazole 500mg TID PO for 10 days   Initial Episode, Severe (WBC >15k, creatinine >1.5) Vancomycin 125 mg PO QID for 10 days Fidaxomicin 200mg PO  BID for 10 days   Initial Episode, Fulminant (Hypotension or shock, ileus, megacolon) Vancomycin 500 mg 4 times per day by mouth or by nasogastric tube. If ileus, consider adding rectal instillation of vancomycin. Intravenously administered 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 (eg, 125 mg 4 times per day for 10–14 days, 2 times per day for a week, 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     Photo Credit Photo by Gabor Monori on Unsplash     The Guidelines McDonald, L. Clifford, et al. "Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)." Clinical Infectious Diseases66.7 (2018): e1-e48. PMID:29462280 Original Studies Teasley, DavidG, et al. "Prospective randomised trial of metronidazole versus vancomycin for Clostridium-difficile-associated diarrhoea and colitis." The Lancet322.8358 (1983): 1043-1046. PMID:6138597 Wenisch, C., et al. "Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of Clostridium difficile—associated diarrhea." Clinical infectious diseases22.5 (1996): 813-818. PMID:8722937 New Evidence Favoring Vancomycin Zar, Fred A., et al. "A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile–associated diarrhea, stratified by disease severity." Clinical Infectious Diseases45.3 (2007): 302-307. PMID:17599306 Johnson, Stuart, et al. "Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: results from two multinational, randomized, controlled trials." Clinical Infectious Diseases 59.3 (2014): 345-354. PMID: 24799326 CDC C. Diff Statistics   New York Times article on the association of the rise of new sweeteners and the rise of C. diff. The Germs That Love Diet Soda

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