Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections
Publication Date: May 31, 2021
Last Updated: March 14, 2022
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.
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- we suggest delivery by enema if other methods are unavailable.
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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
Overview
Title
Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections
Authoring Organization
American College of Gastroenterology
Publication Month/Year
May 31, 2021
Last Updated Month/Year
September 4, 2024
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Hospital
Intended Users
Dietician nutritionist, nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Assessment and screening, Treatment, Management, Prevention
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