Diarrhea ( > 3 unformed stools / 24 hours)

AND either

- Positive C. difficile PCR AND positive toxin A/B

OR

- Presence of pseudomembranous colitis on colonoscopic or histopathologic exam

Initial episode

Vancomycin 125 mg PO q6h for 10 days

OR

Fidaxomicin 200 mg PO q12h for 10 days for patients at increased risk of CDI recurrence (at least 1):

• Age > 65 years old, immunosuppression, history of inflammatory bowel disease
• Concomitant antibiotic use during CDI treatment

≥ 2^nd Recurrence

Vancomycin oral solution in a tapered regimen:

• Vancomycin PO 125mg PO q6h x14 days, then 125mg PO q12h x7 days, then 125mg PO daily x7 days, then 125mg PO every other day x7 days, then 125mg every 3^rd day x14 days

PLUS

ID or GI consult for fecal microbiota transplant (FMT) evaluation (i.e., VOWST) 

Fulminant

Vancomycin 500mg PO q6h

• If ileus is present, add metronidazole 500mg IV q8h and consider Vancomycin 500 mg in 100 mL normal saline given as a retention enema q6h 
• Therapy should be followed by a vancomycin taper (see above)
• ID or GI and surgical consultation should be obtained for severely ill patients.

Vancomycin

125 mg PO q12h

Must meet ALL of the following criteria:

• Recurrent episode of CDI within the past 6 months
• Patient requires treatment with antibiotics (beta-lactams, quinolones, or clindamycin) not directed against CDI in the inpatient setting
• No history of vancomycin allergy

Initiate as soon as possible and continue until antibiotics not directed against CDI are discontinued

VOWST™ (FMT)

ID or GI section approval is required

Place pharmacy non-formulary drug consult (PADR)

Must meet ALL of the following criteria:

• At least 2nd recurrent CDI (3rd CDI episode overall) within previous 12 months
• At least one CDI episode was treated with fidaxomicin, unless not tolerated or contraindicated
• Is able to start VOWST within 2 to 4 days after completing of current CDI treatment

Patients are ineligible if ONE of the following criteria are met:

• Asymptomatic C. difficile colonization
• ANC < 500 cells/m³
• Is likely to require systemic antibiotics or pre-op antibiotics within 8 weeks after treatment
• Inability to use magnesium citrate or polyethylene glycol or take VOWST prior to first meal of day

Pretreatment:

• Take 296 mL magnesium citrate 8 hours prior to first dose of VOWST
  • If renal impairment, prescribe 250 mL polyethylene glycol

Treatment:

• Avoid eating or drinking, except for small amounts of water, for at least 8 hours prior to first dose
• Take 4 capsules of VOWST^TM PO on an empty stomach prior to 1st meal of day once daily x 3 days