Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections

Publication Date: June 1, 2021

Recommendations

PROBIOTICS

1. We recommend against probiotics for the prevention of CDI in patients being treated with antibiotics (primary prevention). ( Moderate , Conditional (weak) )
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2. We recommend against probiotics for the prevention of CDI recurrence (secondary prevention). (Very LowStrong)
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DIAGNOSIS OF CDI

3. CDI testing algorithms should include both a highly sensitive and a highly specific testing modality to help distinguish colonization from active infection. (LowConditional (weak))
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TREATMENT OF CDI

4. We recommend that oral vancomycin 125 mg 4 times daily for 10 days be used to treat an initial episode of nonsevere CDI. (LowStrong)
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5. We recommend that oral fidaxomicin 200 mg twice daily for 10 days be used for an initial episode of nonsevere CDI. (ModerateStrong)
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6. Oral metronidazole 500 mg 3 times daily for 10 days may be considered for treatment of an initial nonsevere CDI in low-risk patients. (ModerateStrong)
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Severe CDI

7. As initial therapy for severe CDI, we recommend vancomycin 125 mg 4 times a day for 10 days. (LowStrong)
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8. As initial therapy for severe CDI, we recommend fidaxomicin 200 mg twice daily or 10 days. (Very LowConditional (weak))
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Management of Fulminant CDI

9. Patients with fulminant CDI should receive medical therapy that includes adequate volume resuscitation and treatment with 500 mg of oral vancomycin every 6 hours daily for the first 48–72 hours. (Very LowStrong)
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Combination therapy with parenteral metronidazole 500 mg every 8 hours can be considered. (Very LowConditional (weak))
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10. For patients with an ileus, the addition of vancomycin enemas (500 mg every 6 hours) may be beneficial. (Very LowConditional (weak))
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Fecal microbiota transplantation for severe and fulminant CDI

11. We suggest FMT be considered for patients with severe and fulminant CDI refractory to antibiotic therapy, in particular, when patients are deemed poor surgical candidates. (LowStrong)
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Treatment of Recurrent CDI

12. We suggest tapering/pulsed-dose vancomycin for patients experiencing a first recurrence after an initial course of fidaxomicin, vancomycin, or metronidazole. (Very LowStrong)
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13. We recommend fidaxomicin for patients experiencing a first recurrence after an initial course of vancomycin or metronidazole. (ModerateStrong)
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PREVENTION OF CDI RECURRENCE

FMT for recurrent CDI

14. We recommend patients experiencing their second or further recurrence of CDI be treated with FMT to prevent further recurrences. (ModerateStrong)
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15. We recommend FMT be delivered through colonoscopy (ModerateStrong)
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  • or capsules for treatment of rCDI.
(ModerateStrong)
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  • we suggest delivery by enema if other methods are unavailable.
(LowConditional (weak))
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16. We suggest repeat FMT for patients experiencing a recurrence of CDI within 8 weeks of an initial FMT. (Very LowConditional (weak))
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OTHER PREVENTION STRATEGIES

Suppressive and prophylactic vancomycin

17. For patients with rCDI who are not candidates for FMT, who relapsed after FMT, or who require ongoing or frequent courses of antibiotics, long-term suppressive oral vancomycin may be used to prevent further recurrences. (Very LowConditional (weak))
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18. Oral vancomycin prophylaxis (OVP) may be considered during subsequent systemic antibiotic use in patients with a history of CDI who are at high risk of recurrence to prevent further recurrence. (LowConditional (weak))
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Bezlotoxumab

19. We suggest bezlotoxumab (BEZ) be considered for prevention of CDI recurrence in patients who are at high risk of recurrence. (ModerateConditional (weak))
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OTHER THERAPEUTIC CONSIDERATIONS

20. We suggest against discontinuation of antisecretory therapy in patients with CDI, provided there is an appropriate indication for their use. (Very LowStrong)
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21. We recommend testing in patients with IBD presenting with an acute flare associated with diarrhea. (, )
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CDI MANAGEMENT IN IBD PATIENTS

CDI diagnosis in IBD

22. We suggest vancomycin 125 mg p.o. 4 times a day for a minimum of 14 days in patients with IBD and CDI. ( Very Low , Strong )
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FMT for CDI in IBD

23. FMT should be considered for recurrent CDI in patients with IBD. (Very LowStrong)
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Recommendation Grading

Disclaimer

Overview

Title

Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections

Authoring Organization

Publication Month/Year

June 1, 2021

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Hospital

Intended Users

Physician, nurse practitioner, nurse, dietician nutritionist, physician assistant

Scope

Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D016360 - Clostridium difficile

Keywords

prevention, management, treatment, Probiotics , Clinical guidelines, Clostridioides difficile Infections

Source Citation

Kelly, Colleen R. MD, AGAF, FACG1; Fischer, Monika MD, MSc, AGAF, FACG2; Allegretti, Jessica R. MD, MPH, FACG3; LaPlante, Kerry PharmD, FCCP, FIDSA4; Stewart, David B. MD, FACS, FASCRS5; Limketkai, Berkeley N. MD, PhD, FACG (GRADE Methodologist)6; Stollman, Neil H. MD, FACG7. ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections. The American Journal of Gastroenterology 116(6):p 1124-1147, June 2021. | DOI: 10.14309/ajg.0000000000001278