Guideline Video

Guideline Resources

  • Management of Clostridioides difficile Infection in Adults
  • American Gastroenterological Association
  • June 30, 2026
  • Summary
  • Full-text

Video Transcription

Just published June 30th, 2026, the American Gastroenterological Association’s newest clinical practice update on Management of Clostridioides difficile Infection in Adults.

The purpose of this update is to provide best practice advice for Clostridioides difficile, or C difficile, infection management.

In today’s rapid update, we’ll just be going over a summary of the best practice advice statements so for the full clinical practice update, make sure to check it out on guidelinecentral.com

Let’s get started.

  • Prevention of C difficile infection should include proper barrier protection and disinfection with United States Environmental Protection Agency–approved sporicidal agents in health care settings. Patients should be counseled on the importance of handwashing and to consider disinfecting areas of the home potentially contaminated with C difficile spores, to prevent reinfection. Reassurance should be provided that C difficile infection transmission to unaffected family members is uncommon.
  • C difficile infection is a clinical diagnosis that requires compatible symptoms in combination with supportive laboratory testing. Multistep testing is preferred for best diagnostic accuracy; however, patients with discordant testing who have a high clinical suspicion for C difficile infection should be treated.
  • Clinicians should classify hospitalized patients with C difficile infection as having nonsevere, severe, or fulminant disease at diagnosis. White blood cell count >15,000 cells/uL and/or creatinine >1.5 × baseline are indicative of severe C difficile infection and increased risk for recurrence and poor outcomes. Patients with additional findings of shock, ileus, or megacolon have fulminant C difficile infection, which can be fatal.
  • Fidaxomicin is a narrower spectrum agent, and given lower recurrence rates, is favored as first-line therapy for nonfulminant C difficile infection. However, given practical considerations, vancomycin is also acceptable therapy. Metronidazole should not be used outside of fulminant disease.
  • Cholestyramine and other bile acid–binding agents should not be used as monotherapy or concurrently with oral vancomycin or fidaxomicin. Psyllium fiber can be used to bulk stools in patients who have recovered from the infection.
  • Following treatment of C difficile infection, clinicians should not perform routine test of cure. Stool testing should only be performed for persistent worsening of diarrheal symptoms.
  • First C difficile infection recurrence within 8 weeks of completing anti–C difficile infection therapy should be treated with either a tapering course of vancomycin or fidaxomicin. Treatment of C difficile infection should include a risk assessment for C difficile infection recurrence and consideration of microbiota restoration therapy to prevent recurrence.
  • Fecal microbiota-based therapies should be offered after treatment of a second recurrence. Microbiota restoration therapy may be considered after treatment of an initial infection or first recurrence in patients who are at high risk for further recurrence or in patients whose initial C difficile infection episode was particularly morbid or difficult to treat.
  • Prolonged, low dose, suppressive vancomycin regimen for secondary prophylaxis may be considered in patients with multiple recurrent episodes who are not candidates for fecal microbiota-based therapies due to ongoing comorbidities, limited life expectancy, or ongoing/frequent systemic antibiotics or who have failed multiple courses of fecal microbiota-based therapy.
  • Fulminant C difficile infection should be managed by a multidisciplinary team and treated with high-dose vancomycin 500 mg every 6 hours, with metronidazole 500 mg intravenously every 8 hours, and if ileus is present, rectal vancomycin 500 mg every 6 hours should be added.
  • Multi-dose fecal microbiota transplantation delivered via lower endoscopy, should be considered in individuals with fulminant C difficile infection. Fecal microbiota, live-jslm, and fecal microbiota spores, live-brpk have not been studied and are not approved for treatment of severe and/or fulminant C difficile infection. Due to high risk of C difficile infection recurrence, patients who recover from severe or fulminant C difficile infection should be maintained on a suppressive vancomycin regimen until a final fecal microbiota transplantation can be administered as an outpatient.
  • Use of vancomycin is not advised during systemic antibiotic administration to prevent C difficile infection. Probiotics are not advised to prevent an initial or recurrent C difficile infection. To promote restoration of healthy gut microbiota, patients should be instructed to consume a healthy diet including a variety of fruits and vegetables, rich in both soluble and insoluble fiber.
  • During the treatment of C difficile infection or the prevention of its recurrence, the use of proton pump inhibitors should be evaluated. If a legitimate indication exists for their use, proton pump inhibitor discontinuation is not necessary.
  • Individuals with a history of C difficile infection should be specifically counseled to avoid unnecessary antibiotic therapy.

And there you have it. Make sure to check out the full clinical practice update from the American Gastroenterological Association and other related clinical decision support tools at guidelinecentral.com.

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