Diagnosis, Treatment, and Prevention of Clostridium difficile Infections
Publication Date: April 1, 2013
Last Updated: March 14, 2022
Recommendations
Diagnostic tests
Only stools from patients with diarrhea should be tested for Clostridium difficile. (Strong “We recommend”, High)
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Nucleic acid amplification tests (NAAT) for C. difficile toxin genes such as PCR are superior to toxins A + B EIA testing as a standard diagnostic test for CDI. (Strong “We recommend”, Moderate)
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Glutamate dehydrogenase (GDH) screening tests for C. difficile can be used in two- or three-step screening algorithms with subsequent toxin A and B EIA testing, but the sensitivity of such strategies is lower than NAATs. (Strong “We recommend”, Moderate)
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Repeat testing should be discouraged. (Strong “We recommend”, Moderate)
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Testing for cure should not be done. (Strong “We recommend”, Moderate)
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Management of mild, moderate, and severe CDI
If a patient has strong a pre-test suspicion for CDI, empiric therapy for CDI should be considered regardless of the laboratory testing result, as the negative predictive values for CDI are insufficiently high to exclude disease in these patients. (Strong “We recommend”, Moderate)
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Any inciting antimicrobial agent(s) should be discontinued, if possible. (Strong “We recommend”, High)
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Patients with mild-to-moderate CDI should be treated with metronidazole 500 mg orally three times per day for 10 days. (Strong “We recommend”, High)
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Patients with severe CDI should be treated with vancomycin 125 mg four times daily for 10 days. (Conditional (weak) “We suggest”, Moderate)
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Failure to respond to metronidazole therapy within 5–7 days should prompt consideration of a change in therapy to vancomycin at standard dosing. (Strong “We recommend”, Moderate)
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For mild-to-moderate CDI in patients who are intolerant/allergic to metronidazole and for pregnant/breastfeeding women, vancomycin should be used at standard dosing. (Strong “We recommend”, High)
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In patients in whom oral antibiotics cannot reach a segment of the colon, such as with Hartman’s pouch, ileostomy, or colon diversion, vancomycin therapy delivered via enema should be added to treatments above until the patient improves. (Conditional (weak) “We suggest”, Low)
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The use of anti-peristaltic agents to control diarrhea from confirmed or suspected CDI should be limited or avoided, since they may obscure symptoms and precipitate complicated disease. Use of anti-peristaltic agents in the setting of CDI must always be accompanied by medical therapy for CDI. (Strong “We recommend”, Low)
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Management of severe and complicated CDI
Supportive care should be delivered to all patients and includes intravenous fluid resuscitation, electrolyte replacement, and pharmacological venous thromboembolism prophylaxis. Furthermore, in the absence of ileus or significant abdominal distention, oral or enteral feeding should be continued. (Conditional (weak) “We suggest”, Low)
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CT scanning of the abdomen and pelvis is recommended in patients with complicated CDI. (Conditional (weak) “We suggest”, Low)
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Vancomycin delivered orally (125 mg four times per day) plus intravenous metronidazole (500 mg three times a day) is the treatment of choice in patients with severe and complicated CDI who have no significant abdominal distention. (Strong “We recommend”, Low)
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Vancomycin delivered orally (500 mg four times per day) and per rectum (500 mg in a volume of 500 ml four times a day) plus intravenous metronidazole (500 mg three times a day) is the treatment of choice for patients with complicated CDI with ileus or toxic colon and/or significant abdominal distention. (Strong “We recommend”, Low)
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Surgical consult should be obtained in all patients with complicated CDI. Surgical therapy should be considered in patients with any one of the following attributed to CDI: hypotension requiring vasopressor therapy; clinical signs of sepsis and organ dysfunction (renal and pulmonary); mental status changes; white blood cell count ≥50,000 cells/μl, lactate ≥5 mmol/l; or failure to improve on medical therapy after 5 days. (Strong “We recommend”, Moderate)
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Management of recurrent CDI (RCDI)
The first recurrence of CDI can be treated with the same regimen that was used for the initial episode. If severe, however, vancomycin should be used. The second recurrence should be treated with a pulsed vancomycin regimen. (Conditional (weak) “We suggest”, Low)
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If there is a third recurrence after a pulsed vancomycin regimen, fecal microbiota transplant (FMT) should be considered. (Conditional (weak) “We suggest”, Moderate)
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There is limited evidence for the use of adjunct probiotics to decrease recurrences in patients with RCDI. (Conditional (weak) “We suggest”, Moderate)
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No effective immunotherapy is currently available. Intravenous immune globulin (IVIG) does not have a role as sole therapy in treatment of RCDI. However, it may be helpful in patients with hypogammaglobulinemia. (Strong “We recommend”, Low)
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Management of patients with CDI and co-morbid conditions
All patients with IBD hospitalized with a disease flare should undergo testing for CDI. (Strong “We recommend”, High)
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Ambulatory patients with IBD who develop diarrhea in the setting of previously quiescent disease, or in the presence of risk factors such as recent hospitalization, or antibiotic use, should be tested for CDI. (Strong “We recommend”, Moderate)
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In patients who have IBD with severe colitis, simultaneous initiation of empiric therapy directed against CDI and treatment of an IBD flare may be required while awaiting results of C. difficile testing. (Conditional (weak) “We suggest”, Low)
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In patients with IBD, ongoing immunosuppression medications can be maintained in patients with CDI. Escalation of immunosuppression medications should be avoided in the setting of untreated CDI. (Conditional (weak) “We suggest”, Low)
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Patients with IBD who have a surgically created pouch after colectomy may develop CDI and should be tested if they have symptoms. (Strong “We recommend”, Moderate)
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Underlying immunosuppression (including malignancy, chemotherapy, corticosteroid therapy, organ transplantation, and cirrhosis) increases the risk of CDI, and such patients should be tested if they have a diarrheal illness. (Strong “We recommend”, Moderate)
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Any diarrheal illness in women who are pregnant or periparturient should prompt testing for C. difficile. (Conditional (weak) “We suggest”, Low)
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Hand hygiene and barrier precautions, including gloves and gowns, should be used by all health-care workers and visitors entering the room of any patient with known or suspected CDI. (Strong “We recommend”, Moderate)
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Infection Control and Prevention
A hospital-based infection control programs can help to decrease the incidence of CDI. (Conditional (weak) “We suggest”, Moderate)
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Routine screening for C. difficile in hospitalized patients without diarrhea is not recommended, and asymptomatic carriers should not be treated. (Strong “We recommend”, Low)
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Antibiotic stewardship is recommended to reduce the risk of CDI. (Strong “We recommend”, High)
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Contact precautions for a patient with CDI should be maintained at a minimum until the resolution of diarrhea. (Strong “We recommend”, High)
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Patients with known or suspected CDI should be placed in a private room or in a room with another patient with documented CDI. (Strong “We recommend”, High)
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Single-use disposable equipment should be used for prevention of CDI transmission. Non-disposable medical equipment should be dedicated to the patient’s room and other equipment should be thoroughly cleaned after use in a patient with CDI. (Strong “We recommend”, Moderate)
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Disinfection of environmental surfaces is recommended using an Environmental Protective Agency (EPA)-registered disinfectant with C. difficile- sporicidal label claim or 5000 p.p.m. chlorine-containing cleaning agents in areas of potential contamination by C. difficile. (Strong “We recommend”, High)
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Although there is moderate evidence that two probiotics (Lactobacillus rhamnosus GG and Saccharomyces boulardii) decrease the incidence of antibiotic associated diarrhea, there is insufficient evidence that probiotics prevent C. difficile infection. (Strong “We recommend”, Low)
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Recommendation Grading
Overview
Title
Diagnosis, Treatment, and Prevention of Clostridium difficile Infections
Authoring Organization
American College of Gastroenterology
Publication Month/Year
April 1, 2013
Last Updated Month/Year
September 3, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
This guideline provides recommendations for the diagnosis and management of patients with CDI as well as for the prevention and control of outbreaks while supplementing previously published guidelines.
Target Patient Population
Patients with Clostridium difficile infections
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, Hospice, Hospital, Long term care, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Management, Treatment
Diseases/Conditions (MeSH)
D016360 - Clostridium difficile, D003015 - Clostridium Infections
Keywords
Clostridium difficile, Clostridioides difficile
Source Citation
American Journal of Gastroenterology: April 2013 - Volume 108 - Issue 4 - p 478-498
doi: 10.1038/ajg.2013.4