Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections

Patient Guideline Summary

Publication Date: June 1, 2021

Last Updated: May 1, 2023

Objective

This patient summary means to summarize key recommendations from the American College of Gastroenterology (ACG) for the prevention, diagnosis, and treatment of Clostridioides difficile Infections. This patient summary is limited to adults 18 years of age and older and should not be used as a reference for children.

Overview

We will use C. difficile to refer to Clostridioides difficile (previously known as Clostridium difficile) and the abbreviation CDI throughout this summary to refer to the disease.

C. difficile infection (other name Clostridium difficile infection) happens when the bacterium produces a toxin (poison) that causes diarrhea and inflammation of the colon.

C. difficile “colonization” is the presence of the organism without symptoms. It is common. Patients carrying the organism when admitted to the hospital are 6 times more likely to develop CDI.

Some of the most common risk factors for active infection include contact with the healthcare environment, old age (65 years or older), and antibiotic use.

Patients in hospitals and long-term care facilities are at the highest risk. Other risk factors include White race, heart disease, chronic kidney disease, and inflammatory bowel disease (IBD).

This patient summary focuses on the diagnosis, management, and prevention of CDI.

Prevention of CDI

ACG does not recommend probiotics (live microorganisms that, when given in adequate amounts, have a health benefit) for:
- preventing CDI if you are being treated with antibiotics (preventing a first infection called “primary infection.”)
- preventing CDI recurrence (preventing another infection called “secondary infection.”)

Diagnosis of CDI

You should be tested only if you have symptoms that suggest active CDI (3 or more unformed stools [loose stools, diarrhea] in 24 hours).

CDI testing should include both a highly sensitive test (a test that can detect people who have the disease) and a highly specific test (a test that excludes people who don’t have the disease) to help distinguish colonization from active infection.

Classification of CDI

ACG recommends the following criteria to classify severe C. difficile infection at the time of diagnosis:
- white blood cell (WBC) count at least 15,000 cells/mm³ or
- serum creatinine >1.5 mg/dL.

ACG recommends defining “fulminant” infection as severe C. difficile infection plus the presence of hypotension (low blood pressure) or shock or ileus (paralysis of the bowel) or megacolon (abnormal, non-mechanical dilation of the colon).

ACG recommended treatment of CDI

Non-severe CDI:
- oral vancomycin 125 mg 4 times daily for 10 days to treat an initial episode.
- oral fidaxomicin 200 mg 2 times daily for 10 days for an initial episode.
- oral metronidazole 500 mg 3 times daily for 10 days for an initial non-severe CDI in low-risk patients.

Severe CDI:
- As initial therapy for severe CDI, vancomycin 125 mg 4 times a day for 10 days.
- As initial therapy for severe CDI, fidaxomicin 200 mg twice daily or 10 days.

ACG recommended management of fulminant CDI
- Medical therapy that includes enough volume resuscitation (replacing lost liquids) and treatment with 500 mg of oral vancomycin every 6 hours daily for the first 48–72 hours. Combination therapy with parenteral (given as an injection and not through the mouth) metronidazole 500 mg every 8 hours can be considered.
- If you have ileus, the addition of vancomycin enemas (500 mg every 6 hours) may be beneficial.

Surgical therapy:
- You may also need surgery based on the clinical circumstances.

Fecal microbiota transplantation for severe and fulminant CDI:
- ACG suggests considering fecal microbiota transplantation (FMT) if you have severe and fulminant CDI not improving with antibiotics, particularly if you are not suitable for surgery.
- FMT uses screened and frozen donor stool (feces) from stool banks.
- Although surgery is the standard option for refractory severe and fulminant CDI, FMT is less invasive and avoids the risks of surgery and the time needed for postoperative recovery.

Treatment of recurrent CDI (rCDI):
- rCDI is defined as the return of diarrhea and a positive C. difficile test within 8 weeks after treatment of an initial episode of CDI.
- ACG suggests tapering/pulsed dose (a different dose schedule) vancomycin if you have a first recurrence after an initial course of fidaxomicin, vancomycin, or metronidazole.
- ACG recommends fidaxomicin if you have a first recurrence after an initial course of vancomycin or metronidazole.

Prevention of CDI recurrence

FMT for recurrent CDI
- ACG recommends FMT to prevent further recurrences if you have a second or later recurrence of CDI.
- ACG recommends FMT be given through colonoscopy (inserting a long, thin instrument with a camera and a tube to look inside your colon and give treatments) or capsules to swallow, or an enema if other methods are unavailable.
- ACG suggests repeat FMT if you have a recurrence of CDI within 8 weeks of an initial FMT.

Other prevention strategies

Supportive and prophylactic (preventive) vancomycin:
- Your doctor may prescribe oral vancomycin to prevent recurrences If you have recurrent CDI, are not suitable for FMT, relapse after FMT, or need ongoing or frequent courses of antibiotics.
- Your doctor may prescribe oral vancomycin prophylaxis (OVP) during subsequent systemic antibiotic use to prevent recurrence if you have a history of CDI and are at high risk of recurrence.

Your doctor may prescribe bezlotoxumab (BEZ) for the prevention of CDI recurrence if you are at high risk of recurrence. BEZ is a drug that binds to a toxin produced by C. difficile and prevents its entrance into the cells lining your bowels.

ACG does not suggest stopping antisecretory therapy (medicines that reduce stomach acid, commonly used for acid indigestion) if you have CDI, provided there is an appropriate cause for their use.

CDI in inflammatory bowel disease (IBD)

Your doctor will probably order C. difficile testing if you have inflammatory bowel disease (IBD) presenting with an acute flare associated with diarrhea.
- That is because patients with IBD have a higher risk of getting CDI.
ACG suggests vancomycin 125 mg by mouth 4 times a day for at least 14 days if you have IBD and CDI.
Your doctor may consider FMT if you have recurrent CDI and IBD.

CDI in pregnancy and breast feeding

Your doctor may prescribe vancomycin to treat CDI if you are pregnant, breast feeding, or shortly after giving birth. In most cases, antibiotics are safe for breastfeeding parents and their babies.

Abbreviations

ACG: American College Of Gastroenterology
BEZ: Bezlotoxumab
CDI: Clostridium Difficile Infection
FMT: Fecal Microbiota Transplantation
IBD: Inflammatory Bowel Disease
OVP: Oral Vancomycin Prophylaxis
rCDI: Recurrent CDI

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

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.