72-year-old woman with abdominal pain and hypotension
A 72-year-old woman presents to the emergency department with 24 hours of worsening abdominal pain and lethargy. She is 9 days post-right hemicolectomy for a benign polyp. She has had no bowel movement today. On examination, she is ill-appearing. Temperature is 38.6°C (101.5°F), heart rate is 125/min, and blood pressure is 85/48 mmHg. The abdomen is distended and diffusely tender with absent bowel sounds. Laboratory studies show a WBC count of 28,500/mcL and serum lactate of 4.8 mmol/L. A stool sample is positive for *Clostridioides difficile* toxin. An abdominal CT scan shows pancolonic wall thickening and megacolon to 8 cm without perforation. Which of the following is the most appropriate next step in management?
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B
Explanation
Clinical Pearl:
Fulminant Clostridioides difficile infection, characterized by hypotension, shock, ileus, or megacolon, requires combination therapy with high-dose oral vancomycin and intravenous metronidazole. Intravenous vancomycin is ineffective as it does not reach the colonic lumen.
Explanation:
This patient presents with fulminant *Clostridioides difficile* infection (CDI), evidenced by her recent surgery, hypotension, ileus (absent bowel sounds), and CT findings of toxic megacolon. According to infectious disease society guidelines, the appropriate management for fulminant CDI is combination therapy with high-dose oral vancomycin and intravenous metronidazole. This regimen provides high intraluminal antibiotic concentrations and systemic coverage for potential bacterial translocation. Administering fidaxomicin orally is a recommended treatment for non-fulminant CDI, but it is not recommended for fulminant disease due to a lack of data in this critically ill population. Intravenous metronidazole alone is insufficient for treating fulminant CDI. Intravenous vancomycin is incorrect because it does not achieve therapeutic concentrations within the colonic lumen. While surgical consultation is crucial in fulminant CDI, initiating appropriate medical therapy is the immediate, life-saving next step, particularly in the absence of perforation.
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