Clostridioides difficile Infection: The Daily PANCE Blueprint
A 68-year-old woman develops profuse watery diarrhea — up to 10 times a day — along with lower abdominal cramping and a low-grade fever. She finished a course of clindamycin for a dental infection about a week ago. Her abdomen is diffusely tender without peritoneal signs, her white-cell count is 15,000, and she is hemodynamically stable. Stool testing is positive for Clostridioides difficile toxin. Which of the following is the most appropriate first-line treatment?
A. Oral metronidazole
B. Intravenous vancomycin
C. Loperamide
D. Oral vancomycin (or oral fidaxomicin)
E. Ciprofloxacin
Answer and topic summary
The answer is D. Oral vancomycin (or oral fidaxomicin).
New antibiotic-associated watery diarrhea with a positive toxin assay — classically after clindamycin, fluoroquinolones, or cephalosporins — is Clostridioides difficile infection. Here is the update that trips people up: oral vancomycin OR oral fidaxomicin is now first-line for an initial episode, and metronidazole has been downgraded to a fallback used only when the preferred agents are unavailable. Intravenous vancomycin does not reach the gut lumen and is useless here (oral is required); loperamide and other antimotility agents are avoided because slowing the gut can precipitate toxic megacolon; and adding another broad-spectrum antibiotic like ciprofloxacin only makes things worse. Also stop the inciting antibiotic whenever possible.
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Covered under ⇒ PANCE Blueprint Infectious Disease ⇒ Bacterial Disease ⇒ Clostridioides difficile Infection
