A 64 y.o man diagnosed with sinusitis is prescribed amoxicil

[madhurima]

A 64 y.o man diagnosed with sinusitis is prescribed amoxicillin for 14 days. On the tenth day of treatment he develops foul smelling , voluminous , non bloody diarrhea . Stool studies are positive for C. difficile toxin. He is given a 7 day course of metronidazole, after which his diarrhea resolves. Repeat stool studies for C. difficile at this time are negative. 3 weeks later , the patient again presents with voluminous watery diarrhea and repeat stool studies are again positive for C. difficile toxin. Which of the following is the most appropriate next step in management?

a) Begin IV vancomycin

b) Begin oral vancomycin

c) Repeat amoxicillin course

d) Repeat metronidazole course

e) Send the patient for colonoscopy

[madhurima]

Answer is D

This patient initially responded to metronidazole and should be treated with another course of it. Following is a stepwise fashion for the approach to patients with reccurent C. difficile colitis:

First episode: Confirm diagnosis and start oral metronidazol therapy (vancomycin is an alternative)

Second episode/first relapse: Confirm Diagnosis and repeat oral metronidazole ( vancomycin is an alternative)

Third episode/second relapse: Start oral tapered and pulsed doses of oral Vancomycin with probiotics.

In patients with Severe colitis, Vancomycin may be considered as the first line therapy.

IV vancomycin is not effective in treating C. difficile colitis because it doesn t pass the lumen of the GI tract.