A 62-year-old man comes to the office for follow-up after recent hospitalization. Two weeks ago, the patient went to the emergency department due to a 3-day history of fever, chills, dysuria, urinary frequency, and low back pain. Evaluation showed a tender and swollen prostate, leukocytosis, pyuria, and bacteriuria. Treatment for acute bacterial prostatitis was begun with intravenous antibiotics. Blood and urine cultures returned positive for Escherichia coli sensitive to all tested antibiotics. The patient was discharged after clinical improvement and was prescribed oral ciprofloxacin. He has had no fever, and urinary symptoms have resolved, but over the last 2 days, he has had mild abdominal cramps and 4 or 5 watery bowel movements per day with no blood or mucus. Other medical conditions include hypertension and type 2 diabetes mellitus. On examination, the patient is afebrile, and other vital signs are within normal limits. There is mild periumbilical tenderness, but physical examination is otherwise unremarkable. Laboratory studies show a leukocyte count of 14,500/mm³ and serum creatinine level of 0.9 mg/dL. Stool testing is positive for Clostridioides difficile.
In addition to oral fidaxomicin therapy, which of the following is the most appropriate next step in management of this patient?

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Explanation: 11ec2b69_bf91_1791_8f63_b7726b3f8594_MD0005_00 This patient who was recently hospitalized and has been on antibiotics for acute bacterial prostatitis (ABP) now has symptoms (eg, abdominal cramping, watery diarrhea) and stool testing consistent with Clostridioides difficileinfection (CDI). Risk factors for CDI include recent hospitalization, advanced age, and recent antibiotic use (most commonly fluoroquinolones, cephalosporins, and clindamycin). Oral fidaxomicin is appropriate treatment for primary CDI in most patients, including those with nonsevere disease, such as this patient, or severe disease; the distinction is typically based on the degree of leukocytosis (severe: >15,000/mm³) or the serum creatinine elevation (severe: >1.5 mg/dL). In addition to the initiation of fidaxomicin therapy, the inciting antibiotic (eg, ciprofloxacin) should be discontinued as soon as possible because its continued use is associated with prolonged diarrhea and increased likelihood of treatment failure (Choice A). If antibiotic therapy is still required to treat the primary infection (eg, ABP), then the inciting medication should be replaced by a lower-risk antibiotic. In this patient with pansensitive Escherichia coli, trimethoprim-sulfamethoxazole is an excellent alternative for the treatment of ABP; a prolonged course (up to 6 weeks) of antibiotics is frequently prescribed to ensure eradication of the organism and prevent complications such as prostatic abscess or chronic prostatitis. treatment of ABP (Choice B) Imaging of the abdomen is indicated in patients with evidence of severe (ie, leukocytes >15,000/mm³, serum creatinine >1.5 mg/dL) or fulminant (eg, septic shock, apparent ileus, megacolon) disease or in those with severe abdominal pain. This patient has only mild disease, so imaging is not required. (Choice C) Ciprofloxacin is a fluoroquinolone associated with the development of CDI, and it should be switched to another antibiotic. However, trimethoprim-sulfamethoxazole is a better choice than amoxicillin-clavulanate because it is a lower-risk antibiotic in patients with CDI and a first-line treatment for ABP. (Choice D) Oral metronidazole is no longer a first-line agent for the treatment of CDI because it is less effective than other agents (eg, fidaxomicin) for achieving a symptomatic cure. In addition, it is not typically used to treat ABP, unlike trimethoprim-sulfamethoxazole, which is a first-line agent with good prostatic penetration. Educational objective: In patients who develop Clostridioides difficile infection (CDI) while taking antibiotics, the inciting antibiotic should be replaced by a lower-risk antibiotic; in addition, appropriate antimicrobial therapy should be started for the CDI. References: Clinical practice guidelines by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 focused update guidelines on management of Clostridioides difficile infection in adults. (http://www.ncbi.nlm.nih.gov/pubmed/34164674) ACG clinical guidelines: prevention, diagnosis, and treatment of Clostridioides difficile infections. (http://www.ncbi.nlm.nih.gov/pubmed/34003176)

A 62-Year-Old Man Comes to the Office for Follow-Up After