A 62-year-old man comes to the emergency department due to a 3-day history of worsening diarrhea and abdominal pain. The patient has had 3-4 watery stools a day with no blood or mucus. The pain is mild, located in the lower abdominal quadrants, and partially relieved with bowel movements. He has had no fever, nausea, or vomiting.
The patient had similar symptoms 6 weeks ago after antibiotic treatment for pneumonia. He was found to have Clostridium difficile infection and was treated with oral vancomycin. The patient had been feeling well after finishing the 10-day treatment until the symptoms recurred. Other medical issues include hypertension, type 2 diabetes mellitus, hyperlipidemia, and depression.
Temperature is 37.2 C (99 F), blood pressure is 110/80 mm Hg, and pulse is 88/min. The abdomen is soft with mild tenderness in the periumbilical and left lower quadrant. There is no rebound tenderness or rigidity.
Laboratory results are as follows:
Stool PCR for C difficile is positive. Which of the following is the best therapy for this patient?

Question

A 62-year-old man comes to the emergency department due to a 3-day history of worsening diarrhea and abdominal pain.  The patient has had 3-4 watery stools a day with no blood or mucus.  The pain is mild, located in the lower abdominal quadrants, and partially relieved with bowel movements.  He has had no fever, nausea, or vomiting.
The patient had similar symptoms 6 weeks ago after antibiotic treatment for pneumonia.  He was found to have Clostridium difficile infection and was treated with oral vancomycin.  The patient had been feeling well after finishing the 10-day treatment until the symptoms recurred.  Other medical issues include hypertension, type 2 diabetes mellitus, hyperlipidemia, and depression.
Temperature is 37.2 C (99 F), blood pressure is 110/80 mm Hg, and pulse is 88/min.  The abdomen is soft with mild tenderness in the periumbilical and left lower quadrant.  There is no rebound tenderness or rigidity.
Laboratory results are as follows:
 Stool PCR for C difficile is positive.  Which of the following is the best therapy for this patient?

Quizplus · Accepted Answer

11ec193a_9800_594d_853d_b7155f88bae8_MD0002_00 This patient most likely has recurrent Clostridium difficile infection (CDI). Recurrence is due to germination of persistent spores from the initial infection and not from drug resistance. Management of the initial recurrence of CDI is typically a prolonged course of oral vancomycin given in a pulsed (QID dosing for 10-14 days) and tapered regimen over a course of 2-8 weeks. Alternately, a 10-day course of fidaxomicin can be administered if vancomycin was used to treat the initial infection. (Choices A and B) Intravenous metronidazole should be added to high-dose oral vancomycin in patients with fulminant infection (eg, shock, ileus, megacolon). Recent guidelines recommend against oral metronidazole for primary or recurrent CDI. Primary CDI should be treated with oral vancomycin or fidaxomicin. (Choice C) Oral vancomycin followed by rifaximin can be used for further recurrences but is not recommended for the first CDI recurrence. (Choice E) Probiotics are not indicated for prevention or treatment of primary CDI in most patients. They can be considered for recurrent non-severe disease as an adjunct, provided the patient has no significant underlying immunosuppression (risk of invasive disease). Educational objective: Initial Clostridium difficile infection is treated with oral vancomycin or fidaxomicin. Intravenous metronidazole should be added to high-dose oral vancomycin in patients with fulminant infection (eg, hypotension, ileus, megacolon). Treatment options for the first recurrence include a prolonged course of oral vancomycin given in a pulsed and tapered regimen or oral fidaxomicin. __________ References: 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) (http://www.ncbi.nlm.nih.gov/pubmed/29462280)

A 62-Year-Old Man Comes to the Emergency Department Due to a 3-Day