[Updated Czech guidelines for the treatment of patients with colitis due to Clostridioides difficile]

Abstract

The updated Czech guidelines differ in some aspects from the 2021 guidelines issued by the ESCMID Study Group for Clostridium difficile. The key points of these Czech recommendations may be summarized as follows: • The drug of choice for hospitalized patients is orally administered fidaxomicin or vancomycin. In outpatients with a mild first episode of C. difficile infection, metronidazole can also be used. • If the patient's response to treatment is good and there are no complications, the duration of antibiotic treatment can be reduced (e.g. to 5 days in case of fidaxomicin or to 6-7 days in case of vancomycin). • If oral therapy is impossible, the drug of choice is tigecycline, 100 mg i.v., b.i.d., with initial shortening of the interval between the first and second doses for faster saturation. If the severity of the disease progresses during this antibiotic treatment, it is necessary to access the ileum or cecum, i.e. to perform double ileostomy or percutaneous endoscopic cecostomy, and to instill vancomycin or fidaxomicin lavages. • Fulminant C. difficile colitis should be treated with oral fidaxomicin ± tigecycline i.v. If peristalsis ceases, fidaxomicin should be administered into the ileum or cecum as described above. If sepsis develops, a broad-spectrum beta-lactam antibiotic (piperacillin/tazobactam, carbapenem) i.v. is added to topically administered fidaxomicin instead of tigecycline i.v.; at the same time, colectomy should be considered as the last resort. • To treat first recurrence, fidaxomicin or vancomycin is administered with a subsequent fecal microbiota transplant (FMT) from a healthy donor. For second or subsequent recurrence, administration of fidaxomicin is of little benefit; the therapy of choice is oral vancomycin and subsequent FMT. Prolonged vancomycin or fidaxomicin taper and pulse treatment is appropriate only when FMT cannot be performed.