ICU · Infectious diseases

Fulminant Clostridioides difficile colitis: surgery, fidaxomicin, and bezlotoxumab

Also known as Fulminant C. difficile · C. difficile colitis · Pseudomembranous colitis · Toxic megacolon C. diff · Fidaxomicin · Bezlotoxumab

Clostridioides difficile infection (CDI) ranges from mild diarrhoea to FULMINANT colitis (hypotension or shock, ileus, megacolon, perforation — reported in-hospital mortality 34.7-53%). RISK FACTORS: elderly patients with comorbidities who have recently received antibiotics; immunosuppression independently predicts fulminant death. DIAGNOSIS: stool toxin testing — toxin EIAs lack sensitivity; NAAT detects toxin genes but detection does not always equate with disease. TREATMENT: (1) INITIAL: fidaxomicin 200 mg PO BD for 10 days (recurrence 15.4% vs 25.3% for vancomycin 125 mg QID — Louie NEJM 2011) or vancomycin 125 mg PO QID. (2) FULMINANT: high-dose enteral vancomycin (500 mg PO/NG QID regimen) + IV metronidazole; early surgical involvement — WBC ≥50 (AOR 18.6) and lactate ≥5 mmol/L (AOR 12.4) carry the highest mortality odds and emergency colectomy was independently associated with survival (AOR 0.22, Lamontagne 2007). (3) SURGERY: total abdominal colectomy is the SIS procedure of choice; diverting loop ileostomy with colonic lavage plus antegrade vancomycin is colon-preserving (19% vs 50% mortality, colon preserved 93% — Neal 2011). (4) RECURRENCE: bezlotoxumab 10 mg/kg single IV infusion (recurrence 17%/16% vs 28%/26% — MODIFY I/II); FMT or bezlotoxumab for second or further recurrence (ESCMID 2021); FMT resolves 81% after one infusion.

Checked against its sources on 2 Sept 2026