How Is Clostridiodes Difficile (C. Diff) Treated?
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Medically reviewed by Jay N. Yepuri, MD
Infection with the Clostridioles difficile (C. diff, or C. difficile) bacteria is a leading cause of diarrhea and colitis (colon, or large intestine, inflammation). It's estimated to cause nearly 500,000 infections annually in the United States.
Anyone is susceptible to C. diff infection, and the condition is contagious. It most often develops in people who have been taking antibiotics for a long time or shortly after people stop using these medications.
C. diff treatment depends on the severity of the infection. Specialists in gastroenterology, hepatology, or infectious disease typically prescribe courses of antibiotics. Additional treatments—like surgery—may be necessary if antibiotics aren't effective.
Treatments by Disease Stage
Healthcare providers categorize C. diff infection based on severity. There are three stages: nonsevere infection, severe infection, and fulminant colitis—the most advanced and potentially fatal form of the condition. Providers also distinguish between initial episodes and recurrences. Recurrences require adjusted treatments.
Treatments for Nonsevere C. Diff Infection
Asymptomatic, nonsevere C. diff is sometimes defined by clinical signs of mild infection: increased white blood cells or levels of creatine (a protein) in your blood. Treatment primarily involves antibiotics. It's only indicated when you have symptoms because side effects can be severe. Here are common options:
Vancocin (vancomycin): For adults, the Infectious Disease Society of America (IDSA) recommends four daily 125 milligram (mg) oral tablets for 10-14 days. One severe side effect is decreased urination.
Dificid (fidaxomicin): Healthcare providers recommend a 10-day course of 200 mg tablets twice daily of this antibiotic. Severe side effects include black or tarry stools, bloody or coffee ground-like vomit, rapid heart rate, stomach pain, and pale skin.
Flagyl (metronidazole): Healthcare providers recommend three 500 mg doses of this antibiotic over 10-14 days. Severe side effects include numbness, burning or pain in your hands or feet, confusion, seizures, difficulty moving or speaking, dizziness, and peeling or blistering skin.
Possible severe side effects of all three antibiotics include:
Rash or hives
Sore throat or stuffy nose
Fever or chills
Breathing difficulties
Seek immediate medical care if you experience any of these side effects.
Treatments for Severe C. Diff Infection
White blood cell and creatine levels are even higher in severe C. diff infections. These infections may require monitoring and hospitalization, especially if initial treatments don’t yield results within five days. Standard therapies include:
Antibiotics: The IDSA recommends a longer and/or different course of antibiotics for severe infections—10 days instead of four—as well as courses of Dificid. These are taken orally.
Colectomy: Severe C. diff infections can cause serious complications, such as toxic megacolon (colon inflammation and enlargement), necrotizing colitis (when part of your colon dies), and perforation of your colon (a hole in your colon). Surgeons treat this by removing all or part of your colon. Common complications include infection, internal bleeding, and hematoma (blood pooling). They occur about 13% of the time.
Ileostomy: This surgical procedure is often performed with a colectomy. The surgeon creates a hole called a stoma in your abdominal wall. The end of your small intestine (the ileum) is connected to this hole. A bag is then connected to the hole to collect stool. Possible complications include infection, necrosis (tissue death around the stoma), and bowel obstruction (blockage).
Treatments for Fulminating Colitis
Fulminating colitis is a severe infection of the colon that causes shock, hypotension (low blood pressure), ileus (inability to move your bowels), and megacolon (deep colon inflammation and enlargement). It's a medical emergency. Healthcare providers will monitor your progress and change the medication and approach based on results. Treatments include:
Enteral vancomycin: In the hospital, providers deliver higher doses of vancomycin—500 mg four times a day—via the enteral route: tubes running directly to your stomach or intestines through your anus or nose.
Parenteral metronidazole: Healthcare providers administer metronidazole parenterally—via intravenous (IV) therapy to your bloodstream—as well as a similar dose of enteral vancomycin: 500 mg every eight hours.
Surgery: Colectomy can remove inflamed or infected parts of your colon if antibiotics don't work or if they cause severe side effects.
Treatments for Recurring Symptoms
About 25% of the time, the C. diff infection reoccurs at least once. This raises the risk of antibiotic resistance, meaning the antibiotics no longer work against the bacteria they're supposed to treat. Treatments for recurring infections include:
Adjusted antibiotics: Your healthcare provider may prescribe a different antibiotic or increase the dose. For instance, treatment guidelines recommend Vancocin if you’ve already tried Flagyl. Second recurrences require 20-day courses of another antibiotic, Xifaxan (rifaximin), following Vancocin.
Prolonged taper with pulsed vancomycin: This involves a 10-14 day course of 125 mg of Vancocin four times daily, followed by one week of two doses daily, one week of one dose daily, and two weeks to two months of one dose every 2-3 days.
Zinplava (bezlotoxumab): Zinplava is a U.S. Food and Drug Administration (FDA) approved monoclonal antibody that might help prevent recurrence. Providers give IV doses based on weight alongside IV antibiotics. This therapy raises the risk of heart failure in people with a history of heart conditions.
Fecal microbiota transplant: This surgical procedure involves transplanting feces (poop) from a healthy donor to the affected colon. The feces contain bacteria that can prevent C. diff from multiplying and returning. The procedure is done using an adjustable tube (colonoscope), by swallowing a tablet, or via the enteral route (a tube from your anus or nose to your stomach or intestines).
Living With and Managing C. Diff Infection
The prognosis for a C. diff infection depends on how severe it is. Other health factors, especially age, also play a role. According to the Centers for Disease Control and Prevention (CDC), one in 11 people over the age of 65 die within a month of developing the infection. The infection returns within 4-6 weeks in about one in six people who contract it.
Most C. diff cases aren’t deadly—and many pass without the need for therapy—but this condition can lead to serious complications. In multiple studies of patients hospitalized with infection in the U.S., 6-11% of people died within one month. One study in South Korea found about 75% of the study population (120 patients) survived for one year, but the survival rate dropped to 50% within five years.
Researchers continue to develop newer medications and therapies, including ridizanole. This is a promising new type of antimicrobial drug for C. diff. These will hopefully further improve outcomes for people with severe C. diff infections or fulminant colitis.
A Quick Review
C. diff infection is a cause of diarrhea and other symptoms often linked to prolonged use of antibiotic medications. The treatment approach depends on severity and individual factors.
The primary C. diff treatment approaches include antibiotics, surgery removing parts of the colon, and fecal transplant (transplanting feces from a healthy donor).
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