Pseudomembranous Colitis Treatment & Management

  • Author: Jennifer A Curry, MD, MPH; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Sep 6, 2011
 

Medical Care

  • Stop the offending agent if possible. In about 20% of patients, CDI resolves within 2-3 days of antibiotic discontinuation, without further therapy.
  • Given the potential morbidity of C difficile infection, treatment should be initiated immediately rather than waiting for potential resolution of symptoms. In mild cases that are brought to clinical attention and are diagnosed after the resolution of symptoms, withholding antibiotics may be reasonable.
  • Provide supportive care for the diarrhea, including repletion of fluid and electrolyte losses.
    • Antiperistaltic agents and opiates should be avoided, as slowing of fecal transit time is thought to result in extended toxin-associated damage.
  • Test confirmation of C difficile involvement is indicated prior to treatment, provided the patient is not critically ill. Empiric treatment prior to confirmation of diagnosis is recommended in critically ill patients, but stool samples for analysis should be obtained within 48 hours of therapy initiation.
  • Implement contact isolation precautions (gowns and gloves) to reduce the spread of C difficile to other hospitalized patients.
  • Patients generally respond to 10-14 days of metronidazole or vancomycin therapy (see Medication); however, patients with severe colitis or underlying GI conditions (eg, irritable bowel syndrome, lactose intolerance) may require prolonged courses of therapy.
  • Treatment of completely asymptomatic carriers (including health care workers) remains controversial, although a significant reduction in carriage rate has been successfully reported with oral vancomycin
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Surgical Care

Surgical intervention is usually indicated for patients whose conditions are complicated by toxic megacolon with subsequent risk for perforation or existing perforation. The frequency of surgical intervention is low, reported at 0.39-3.6% of cases of C difficile –associated colitis. The overall mortality rate for patients requiring colectomy for severe, complicated CDAD is reportedly as high as 75%, reflecting its use as a therapy of last resort. Several studies have emphasized the importance of early surgical intervention if indicated (eg, prior to end organ failure or lactate >5).[25] Less invasive approaches including laparoscopic creation of a diverting ostomy have been described[26] ; these may improve mortality by facilitating earlier intervention.

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Consultations

  • Gastroenterologist for endoscopy, if indicated
  • General surgeon if toxic megacolon or perforation is present or possible
  • Infectious disease specialist or gastroenterologist for recurrent disease
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Diet

Recommendations should be based on the severity of the symptoms. For moderate-to-severe cases, a clear liquid diet is recommended until the patient’s diarrhea resolves.

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Activity

Activity is as tolerated, depending on degree of symptoms.

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Contributor Information and Disclosures
Author

Jennifer A Curry, MD, MPH  Attending Physician, Infectious Disease Clinic, Naval Medical Center Portsmouth; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences

Jennifer A Curry, MD, MPH is a member of the following medical societies: American College of Physicians, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Gary L Gorby, MD  Associate Professor, Departments of Internal Medicine and Medical Microbiology and Immunology, Division of Infectious Diseases, Creighton University School of Medicine; Associate Professor of Medicine, University of Nebraska Medical Center; Associate Chair, Omaha Veterans Affairs Medical Center

Gary L Gorby, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and New York Academy of Sciences

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Joseph F John Jr, MD, FACP, FIDSA, FSHEA  Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgments

The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. government.

LCDR Jennifer Curry is a military service member. This work was prepared as part of official duties. Title 17 U.S.C. §105 provides that ‘Copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C. §101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties.

Many thanks to Duane R Hospenthal, MD, PhD, Joseph Lee, MD, and Braden Hale, MD, MPH for their work on earlier versions of this topic.

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Colonic pseudomembranes of pseudomembranous colitis. Photographs courtesy of Eric M. Osgard, MD.
 
 
 
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