ICU · Antimicrobial Stewardship

Clostridioides difficile infection in the ICU

Also known as C. difficile infection (CDI) · Pseudomembranous colitis · C. diff colitis · Fidaxomicin · Faecal microbiota transplant (FMT) · Bezlotoxumab · Toxin A / Toxin B · NAP1/BI/027 hypervirulent strain

Clostridioides difficile infection (CDI) is a toxin-mediated complication of antibiotic use, on a spectrum that runs from asymptomatic colonisation through self-limiting diarrhoea to toxic megacolon and fulminant colitis. Clindamycin-associated colitis (1974) is the index report; 3-10% of patients progress to severe, complicated (fulminant) disease. SEVERE = leukocytosis (WBC at least 15,000 cells/mL) or creatinine over 1.5 mg/dL; FULMINANT = hypotension or shock, ileus, or megacolon (Surgical Infection Society definitions). TREATMENT: stop the inciting antibiotic; fidaxomicin 200 mg PO BD or vancomycin 125 mg PO QID x 10 days (recurrence 15.4% vs 25.3%, Louie NEJM 2011; fidaxomicin preferred per ESCMID 2021); fulminant: vancomycin 500 mg PO/NG four times daily plus IV metronidazole 500 mg every 8 hours (rectal vancomycin 500 mg in approximately 100 mL saline every 6 hours if ileus) per IDSA/SHEA 2017, with early surgical review - total abdominal colectomy is the SIS procedure of choice. Bezlotoxumab 10 mg/kg IV once, with antibiotics, cuts 12-week recurrence (17% vs 28%, MODIFY I). FMT for second or further recurrence.

Checked against its sources on 5 Sept 2026