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We recommend discontinuing metronidazole because the side effects (nausea, vomiting, and taste disturbances) may be mistaken for patients with signs of ileus due to worsening CDI, and because there is insufficient evidence to support the practice of continuing metronidazole for mild-to-moderate CDI when a decision to escalate therapy to vancomycin has been made.
As a result, it has become common practice to use higher doses of vancomycin if patients are failing to respond to the standard recommended dose of 125 mg four times daily. A trial of 46 patients randomized to 500 or 125 mg of vancomycin four times daily for the initial treatment of CDI showed no difference in duration of diarrhea, relapse rate, or microbiological cure (carriage of C.
Moreover, fecal levels of vancomycin in patients with CDI with this dose achieve levels that are a minimum of 10 times the minimal inhibitory concentration reported for C. Metronidazole treatment should be avoided in pregnancy and breast feeding.