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As stool examinations are imperfect, clinical judgment is still vital. Importantly, oral metronidazole monotherapy is not an appropriate initial treatment for patients at highest risk, in particular, those who present with significant predictors of disease severity or are of advanced age and have worrisome comorbidities.
Given the rather poor enteric absorption of vancomycin, an increase in toxicity would not be anticipated. In the VA study by Musher and colleagues, 30 of the 46 patients who still had symptoms after 10 days of metronidazole therapy were treated with a prolonged course.