Journal List > Korean J Gastroenterol > v.54(1) > 1006617

Park and Han: Management of Antibiotics-Associated Diarrhea

Abstract

Antibiotics-associated diarrhea (AAD) is defined as unexplained diarrhea that occurs with the administration of antibiotics. Approximately 20% AAD cases are due to Clostridium difficile. Over the last decade, the incidence of Clostridium difficile-associated disease (CDAD) has progressively increased, and now a significant clinical problem. Recent change in the epidemiology of CDAD and the emergence of an epidemic hypervilruent strain suggest the need for greater attention for infection control, early diagnosis, and more effective treatment modality. However, since most cases of CDAD are both iatrogenic and nosocomial, careful selection of antibiotics, combined with proper hand hygiene and precaution by medical staffs are required.

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Table 1.
Clinical Manifestation and Treatment
Severity Clinical setting Treatment
Asymptomatic Observation
Mild to moderate Mild diarrhea Stop predisposing antibiotics
Hydration
Isolation
Consider probiotics
Oral or intravenous metronidazole
Oral vancomycin if intolerable to metronidazole
Severe (Bloody) diarrhea >12 stools/d As above plus:
Pseudomembranous colitis Oral vancomycin daily
Severe abdominal pain Addition of intravenous metronidazole daily
Ileus
Fever
Old age
In intensive care unit
Leukocytosis
Hypoalbuminemia
Renal failure
Fulminant Toxic megacolon As above plus:
Hypoalbuminemia Surgical consultation
Renal failure Oral vancomycin daily and intravenous
Respiratory distress metronidazole daily
Hemodynamic instability Consider immunoglobulin

Modified from Leffler DA.33

Table 2.
Treatment of Recurrent C. difficile Infection
Initial recurrence
14-day course of oral metronidazole or vancomycin
Consider probiotics
Second recurrence
Tapered pulse dose oral vancomycin
125 mg 4 times daily for 1 week
125 mg twice for 1 week
125 mg daily for 1 week
125 mg every other day for 1 week
125 mg every third day for 2 weeks
Consider 1-month course of probiotics starting in the final 2 weeks of antibiotics therapy
Third or subsequent recurrence
Tapered pulse dose oral vancomycin followed by
14-day course of rifaximin, nitazoxanide, or toxin binding agents
Consider 1-month course of probiotics starting in the final 2 weeks of antibiotic therapy
Consider intravenous immunoglobulin or fecal bacteriotherapy
Consider chronic low-dose suppressive therapy with oral vancomycin for eldery patients and those with multiple comorbidities
Data are from Leffler DA.33
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