C. Diff treatment

[stridor]

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I recently saw a practice question that had a patient with C. Diff and options for treatment were vancomycin and metronidazole. Is there one that is preferred, and if so why?

 

[commander]

I recently saw a practice question that had a patient with C. Diff and options for treatment were vancomycin and metronidazole. Is there one that is preferred, and if so why?

Flagyl is the treatment of choice
The only indication for vancomycin is if symptoms dont resolve after 14 days of treatment. and that is po vanco.

 

[jdh71]

Flagyl is the treatment of choice
The only indication for vancomycin is if symptoms dont resolve after 14 days of treatment. and that is po vanco.

Kind of . . .

PO Metronidazole is the 1st choice for c-diff
PO Metronidazole is used for 1st relapse
PO Vanco is used for 2nd relapse
PO Vanco and IV Metronidazole for c-diff requiring ICU admission

So it's both. It's been studied and vanco = metronidazole for efficacy generally, but metronidazole is the currently recommended first line agent.

 

[werd]

jdh is right. i think we don't use vanc first line because vre and vanc resistance in general are very problematic things. i think there's some evidence for superiority of vanc in very sick patients but in general they both usually work.

on a test, the answer will almost always be metronidazole AND stop all unnecessary antibiotics.

 

[km11]

I think the new guidelines that came out last year by the ID society (i forgot their officia acronym) say metronidazole for 1st and 2nd relapse UNLESS it is "severe", which is when you use PO vanc. They have some criteria for what counts as severe but at the hospital i rotated through, it was more of a feel thing. If a patient was pretty sick, pretty old or some combination there of, we would just give them vanc. After 2nd relapse, I think the treatment of choice is vanco pulse/taper and can consider rifaximin.

I would guess theres a lot of regional variation in when people choose to give vanc based on local bacteriograms etc.

(I still say we should just fecal transplant everyone, if nothing but for the sake of saying you're fecal transplanting someone)

 

[hot sauce]

Just a note that could be easily overlooked but was it PO vanco or IV vanco on the options? Obviously IV would be incorrect. Sometimes the questions try to trick you with details like that.

Having said that I would agree with previous posts that first line is metro (in general).

 

[NickHome]

PO Metronidazole

 

[Beamer128]

new SHEA guidelines

http://www.journals.uchicago.edu/action/showFullPopup?doi=10.1086/651706&id=tb3

 

[KissMyAsthma98]

check epocrates

 

[OveractiveBrain]

All this blah blah about recommendations doesnt help answer a multiple choice question. The information is correct, but the Step 2 does not expect you to read all the 2010 recommendations from the individual societies. You should know what the standard of care is; what has been set in stone and what you learn in medical school; i.e. what is in textbooks.

So, in general, whenever you are posed with two seemingly identical answers, pick the one that is cheaper. This can be applied to ANY practice question where there are two equally as effacious treatments or tests; the cheaper one is usually the right answer.

In terms of efficacy, vanco = metro
In terms of cost, vanco >> metro.

Bottom line, you should not be posed with equally effacious answers on the real test. Step 2 questions are much better written and analyzed over the thousands of Kaplan or USMLE world questions.

If you knew that vanc = metro in treatment for C. Diff, youre in good shape, move on.

 

[Rendar5]

ignore current ID guidelines. This is a test, not the real world. In the test world flagyl is first line regardless unless there's an allergy to it.