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Either vancomycin or fidaxomicin is recommended over metronidazole for an initial episode of CDI. The dosage is vancomycin 125 mg orally 4 times per day or fidaxomicin 200 mg twice daily for 10 days (strong recommendation, high quality of evidence ) ( Table 1 ).

In settings where access to vancomycin or fidaxomicin is limited, we suggest using metronidazole for an initial episode of nonsevere CDI only (weak recommendation, high quality of evidence ). The suggested dosage is metronidazole 500 mg orally 3 times per day for 10 days. Avoid repeated or prolonged courses due to risk of cumulative and potentially irreversible neurotoxicity (strong recommendation, moderate quality of evidence ). (See Treatment section for definition of CDI severity.)

Table 1.

Recommendations for the Treatment of Infection in Adults

Abbreviations: FDX, fidaxomicin; VAN, vancomycin.

All randomized trials have compared 10-day treatment courses, but some patients (particularly those treated with metronidazole) may have delayed response to treatment and clinicians should consider extending treatment duration to 14 days in those circumstances.

The criteria proposed for defining severe or fulminant infection (CDI) are based on expert opinion. These may need to be reviewed in the future upon publication of prospectively validated severity scores for patients with CDI.

The opinion of the panel is that appropriate antibiotic treatments for at least 2 recurrences (ie, 3 CDI episodes) should be tried prior to offering fecal microbiota transplantation.

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Table 1.

Recommendations for the Treatment of Infection in Adults

Abbreviations: FDX, fidaxomicin; VAN, vancomycin.

All randomized trials have compared 10-day treatment courses, but some patients (particularly those treated with metronidazole) may have delayed response to treatment and clinicians should consider extending treatment duration to 14 days in those circumstances.

The criteria proposed for defining severe or fulminant infection (CDI) are based on expert opinion. These may need to be reviewed in the future upon publication of prospectively validated severity scores for patients with CDI.

The opinion of the panel is that appropriate antibiotic treatments for at least 2 recurrences (ie, 3 CDI episodes) should be tried prior to offering fecal microbiota transplantation.

View Large

1. For fulminant CDI*, vancomycin administered orally is the regimen of choice (strong recommendation, moderate quality of evidence ). If ileus is present, vancomycin can also be administered per rectum (weak recommendation, low quality of evidence ). The vancomycin dosage is 500 mg orally 4 times per day and 500 mg in approximately 100 mL normal saline per rectum every 6 hours as a retention enema. Intravenously administered metronidazole should be administered together with oral or rectal vancomycin, particularly if ileus is present (strong recommendation, moderate quality of evidence ). The metronidazole dosage is 500 mg intravenously every 8 hours.*

The scenario subset selection transformation ( T 2 ) involves determining which values of f ( x i ,  S ) to use in the robustness metric calculation ( T 3 ) (i.e., f ( x i ,  S ) ⊆  f ( x i ,  S )), which is akin to selecting a subset of the available scenarios over which system performance is to be assessed. This reflects a particular degree of risk aversion, where consideration of more extreme scenarios in the calculation of a robustness metric corresponds to a higher degree of risk aversion and vice versa. As can be seen from Table 1 , which scenarios are considered in the robustness calculation is highly variable between different metrics.

The third transformation ( T 3 ) involves the calculation of the actual robustness metric based on transformed system performance values ( T 1 ) for the selected scenarios ( T 2 ), which corresponds to the transformation of f ( x i ,  S ) to a single robustness value, R ( x i ,  S ). This equates to an identity transform in cases where only a single scenario is selected in T 2 , as there is only a single transformed performance value, which automatically becomes the robustness value. However, in cases where there are transformed performance values for multiple scenarios, these have to be transformed into a single value by means of calculating statistical moments of these values, such as the mean, standard deviation, skewness or kurtosis.

In this section, a taxonomy of different robustness metrics is given in accordance with the three transformations introduced in Section 2 . A summary of the three transformations, as well as the relative level of risk aversion, is provided in Section 3.4 .

A categorization of different robustness metrics in accordance with the performance value transformation ( T 1 ) is given in Table 2 . As can be seen, the categorization is based on (1) whether calculation of a robustness metric is based on the absolute performance of a particular decision alternative or the performance of a decision alternative relative to that of another decision alternative or a benchmark; and (2) whether a robustness metric provides an indication of actual system performance or whether system performance is satisfactory compared with a pre‐specified performance threshold.

Many of the classic decision analytic robustness metrics belong to the bottom‐right hand quadrant of Table 2 , including the maximax and maximin criteria, Hurwicz's optimism‐pessimism rule and Laplace's principle of insufficient reason, as well as well more recently developed metrics such as the mean‐variance criterion, percentile based skewness and percentile‐based peakedness. These metrics utilize information about the absolute performance (e.g., cost, reliability) of a particular decision alternative in a particular scenario. Consequently, values of f ( x i ,  S ) consist of these performance values, and robust decision alternatives are those that maximize system performance across the scenarios. The difference between these metrics is which values of the distribution of performance values over the different scenarios f ( x i ,  S ) they use in the robustness calculation (i.e., scenario subset selection ( T 2 )) and how these values are combined into a single value of R (i.e., robustness metric calculation ( T 3 )), as discussed in Sections 3.2 and 3.3 .

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