Abstract
Fulminant Clostridioides difficile infection (FCDI) encompasses 3 to 5% of all CDI cases with associated mortality rates
between 30 and 40%. Major treatment modalities include surgery and medical management
with antibiotic and nonantibiotic therapies. However, identification of patients with
CDI that will progress to FCDI is difficult and makes it challenging to direct medical
management and identify those who may benefit from surgery. Furthermore, since it
is difficult to study such a critically ill population, data investigating treatment
options are limited. Surgical management with diverting loop ileostomy (LI) instead
of a total abdominal colectomy (TAC) with end ileostomy has several appealing advantages,
and studies have not consistently demonstrated a clinical benefit with this less-invasive
strategy, so both LI and TAC remain acceptable surgical options. Successful medical
management of FCDI is complicated by pharmacokinetic changes that occur in critically
ill patients, and there is an absence of high-quality studies that included patients
with FCDI. Recommendations accordingly include a combination of antibiotics administered
via multiple routes to ensure adequate drug concentrations in the colon: intravenous
metronidazole, high-dose oral vancomycin, and rectal vancomycin. Although fidaxomicin
is now recommended as first-line therapy for non-FCDI, there are limited clinical
data to support its use in FCDI. Several nonantibiotic therapies, including fecal
microbiota transplantation and intravenous immunoglobulin, have shown success as adjunctive
therapies, but they are unlikely to be effective alone. In this review, we aim to
summarize diagnosis and treatment options for FCDI.
Keywords
colectomy - fecal microbiota transplantation - fidaxomicin - vancomycin - metronidazole
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Clostridium difficile
