Difficulties and Differences on C difficile
Paul Sax • May 7th, 2012
Some things in our field — diseases, treatments, generalizations, cliches, fads — have really changed since back in the early 1990s, when I started in this business.
Here are a few that quickly come to mind:
- “Double coverage” of pseudomonas with a beta lactam plus an aminoglycoside was de rigueur
- MRSA was an inpatient concern only
- You never saw Lyme disease in the winter or in people who hadn’t left urban areas
- Mycobacterium avium complex was more of a problem in people with AIDS than in middle-aged, slender women who coughed
- Kids still got epiglottitis and meningitis from H flu
- Life-threatening colitis from C difficile was an exceedingly rare event, and barely ever occurred in otherwise healthy people
Yes, C diff has changed a lot — and not for the better. However, one thing that hasn’t changed about C diff is the controversy over treatment, something we’re grappling with now.
Should initial therapy be metronidazole? Or vancomycin? Or vancomycin just for severe cases? Or fidaxomicin? What if cost were no issue?
How long should you treat, especially when the patient is still on antibiotics? What do you do about relapses? Probiotics? Tapering schedules? Fecal transplants? In severe cases, is diverting ileostomy an alternative to colectomy?
I don’t have the answers, just some opinions — which I’m happy to share — but first I’d be thrilled to get some outside views, if only on the initial therapy question.