Current Treatment Options for Severe Clostridium difficile-associated Disease.

A notable trend toward severe Clostridium difficile colitis and poor outcomes has emerged since recognition of the hyper-virulent C. difficile NAP1/027 strain. This trend has increased the emphasis on appropriate treatment regimens in refractory cases of C. difficile infection. In mild-to-moderate cases, oral metronidazole remains adequate first-line therapy, but in the absence of a good clinical response, switching to vancomycin may be necessary. Oral vancomycin should be used as initial therapy in severely ill patients or patients who cannot tolerate metronidazole. Rectal administration of vancomycin may be used as adjunctive therapy for severely ill patients. Patients with an ileus who cannot tolerate oral medications may improve with adjunct intravenous metronidazole and/or rectal vancomycin. Early surgical consultation should be requested, as some patients will require emergent colectomy. The shifting landscape of C. difficile infection has undermined our complacency regarding this long-recognized disease.