In this episode, I’ll discuss the treatment of fulminant C. diff.
In older IDSA guidelines, the term “severe complicated” was used to describe the sickest group of patients with C. diff infection. In the most recent guidelines, patients with C. diff and hypotension, shock, or ileus are now said to have “fulminant C. diff.”
Treatment of fulminant C. diff continues to involve Vancomycin 500 mg 4 times per day by mouth or by nasogastric tube PLUS IV metronidazole 500 mg q8h. Be aware of the concern that oral vancomycin may not reach the bowel if an ileus is present. If ileus is present or suspected, the guidelines recommend adding vancomycin 500 mg in approximately 100 mL normal saline per rectum every 6 hours as a retention enema.
When treating a patient with oral and rectal vancomycin who has fulminant C. diff, it is reasonable to check at least one vancomycin serum level. Although vancomycin is not absorbed enterally, there are reports of patients with fulminant C. diff experiencing absorption and having potentially significant serum vancomycin concentrations.
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