Rifaximin in Combination With Metronidazole and Oral Vancomycin for the Treatment of an Initial Episode ofClostridium difficile-Associated Diarrhea: Case Report and Literature Review

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Example of successful use of rifaximin in the treatment of an apparent Clostridium difficile infection refractory to vancomycin and metronidazole with literature review.

Case Summary:

A 69-year-old Caucasian female developed C. difficile infectious diarrhea, con-firmed by enzyme immunoassay (EIA) test. Following diagnosis, the patient was initiated on a treatment regimen of intravenous (IV) metronidazole and oral vancomycin. The patient sought additional medical treatment 3 days after initiating this treatment regimen. She presented with continued symptoms of diarrhea, bloating, anorexia, weakness, and leukocytosis nonresponsive to metronidazole and vancomycin. After a total of 7 days of treatment with metronidazole and vancomycin, the patient remained symptomatic with loose stools occurring approximately every 2 hours. Oral rifaximin 400 mg 3 times a day was added to the regimen, after which the patient's symptoms improved rapidly.


A patient with presumed C. difficile-associated diarrhea refractory to metronidazole and vancomycin was successfully treated after the addition of oral rifaximin 400 mg 3 times a day. Based on current literature and this case, rifaximin should not replace metronidazole or vancomycin as primary therapy for presumed or diagnosed C. difficile but should be retained as a useful alternative, especially in light of limited alternatives.

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