Case 1: According to the most recent practice guidelines for the treatment of C difficile infection, published in 2010 by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA), the initial agent of choice depends on the disease severity. The SHEA and IDSA recommend that for an initial episode of C difficile, metronidazole 500 mg by mouth 3 times daily for 10 to 14 days may be used in patients with mild-to-moderate disease (defined by the SHEA/IDSA as elevated white blood count, but <15,000 cells/μL and a serum creatinine <1.5 times the baseline level). For severe disease (defined as elevated white blood count >15,000 cells/ μL and a serum creatinine >1.5 times the baseline level), the SHEA and IDSA recommend the initial use of vancomycin 125 mg by mouth 4 times daily for 10 to 14 days. An initial episode is also considered to be severe and complicated if the patient exhibits hypotension, shock, ileus, or megacolon. In these cases, the recommended treatment is vancomycin 500 mg by mouth 4 times daily in addition to metronidazole 500 mg intravenously every 8 hours. Based on QW’s presentation, vancomycin 125 mg by mouth 4 times daily for 10 to 14 days would be an appropriate recommendation to the team.
Case 2: Benzodiazepines, in particular lorazepam (Ativan), are considered by most to be the first drug to be used in the treatment of GCSE. Lorazepam is administered as 4 mg intravenously (IV) at a rate of 2 mg per minute. An additional dose of 4 mg IV (at the same rate) can be administered if RT’s seizure continues or if it recurs after 10 to 15 minutes. If lorazepam fails to adequately control GCSE, phenytoin sodium is typically administered as second-line therapy. Third-line drugs for refractory status epilepticus (defined as failing to respond to both benzodiazepine and phenytoin therapies) often include phenobarbital, midazolam, propofol, pentobarbital, valproate, levetiracetam, or lidocaine.