Therapeutic targets
- Elimination of the pathogens
- Rehydration (fluid balance)
- Termination of diarrhea (diarrhea)
Therapy recommendations
- Discontinuation of the antibiotic causing the disease!
- Symptomatic therapy including fluid replacement
- Oral rehydration for signs of dehydration (fluid deficiency; >3% weight loss): administration of oral rehydration solutions (ORL), which should be hypotonic, between meals (“tea breaks”) for mild to moderate dehydration
- Balancing the electrolytes (blood salts).
- Note: Administration of motility inhibitors (drugs that dampen intestinal peristalsis) is not recommended.
- Initial illness: antibiotic therapy (10 days); drug of first choice is now no longer metronidazole but vancomycin; indications (see below):
- (Metronidazole – in mild to moderate disease expression and lack of risk factors for a severe course)Note: Vancomycin is increasingly used because of its superiority even in mild to moderate disease expression and lack of risk factors for a severe course.
- Vancomycin – in severe disease expression or the presence of risk factors for a severe course; in pregnant women, in children under 10 years of age, and during therapy with tofacitinib [see “Further notes” below].
- Fidaxomicin – if there is an increased risk of relapse and risk factors for complications are present (such as immunosuppression, comorbidities/co-existing conditions), therapy with fidaxomicin may be considered.N.B : During treatment with fidaxomicin, the environment is less likely to be contaminated with spores (36.8%) than during therapy with vancomycin and/or metronidazole
- Combination of vancomycin (p.o. or via enteral tubes) and metronidazole (i.v. ): in life-threatening clinical pictures (e.g. toxic megacolon)Possibly, tigecycline i. v. (representative of the glycylcycline class) is a better alternative to metronidazole.
Therapy usually leads to clinical improvement within 48 to 72 hours; however, does not lead to a permanent cure in 15-23% of patients!
- Recurrent treatment
- First relapse: treatment recommendations analogous to the initial illness according to the DGVS guideline on infectious gastroenteritisFidaxomicin seems to be the most appropriate relapse therapy. Notice: According to the criteria of the Robert Koch Institute, recurrent CDI is defined as a “severe CDI”!
- Second recurrence: vancomycin creep or pulse regimen or with fidaxomicin (recurrence rate after fidaxomicin therapy is significantly lower than after treatment with vancomycin).
- For recurrent (reoccurring) Clostridium difficile infections, the effectiveness of vancomycin therapy decreases with the number of infection recurrences.
- Bezlotoxumab: therapy for patients at high risk of recurrence (defined as age > 65 years, history of one or more CDI episodes in the past 6 months, immunosuppression, severe CDI infection, ribotype 027, 078, or 244).
- Fecal transplantation (fecal microbiome transfer, FMT) – to rebuild intestinal flora (intestinal microbiota.
- Method of choice in cases of multiple drug recurrence failure or.
- Complicated recurrences of Clostridium difficile infection).
- The Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) guideline recommends fecal microbiota transplantation (“strong recommendation, moderate quality of evidence”) for the treatment of Clostridium difficile-associated diarrhea (CDAD) for the first time.
- Fecal microbiome transfer is performed in the symptom-free interval (= relapse prophylaxis).
- Cure rate: see below Further therapy/conventional non-surgical therapy methods.
- See also under “Further therapy”.
Indications for antibiotic therapy:
- Severe symptomatology
- Persisting symptomatology
- Individuals with severe underlying diseases
- Elderly persons
- Continuation of current therapy necessary
Further notes
- The updated U.S. guideline (published February 15, 2018) for the treatment of Clostridium difficile infection (CDI) provides for first-line use of oral vancomycin ( 4 x 125 mg/day p. o. for at least 10 days) in adults, even for mild and moderate forms of disease [see guidelines below].
- Passive immunization: the monoclonal antibody bezlotoxumab, which neutralizes toxin B of C. difficile bacteria, significantly reduced the rate of recurrence of intestinal infection in two phase 3 trials (MODIFY I and II). In these trials, ten patients had to be treated to prevent CDI recurrence (recurrence of the disease).Side effects: Nausea, diarrhea (diarrhea), fever and headacheCave (Warning): risk of heart failure in patients with a history (medical history) of heart failure (heart failure).
