Updated guidelines on the management of Clostridium difficile infection (CDI), with a focus on the use of faecal microbiota transplant, have been published by the British Society of Gastroenterology and Healthcare Infection Society.
The guidelines support the use of faecal microbiota transplant (FMT) as a second-line treatment option in patients with recurrent or refractory CDI, after considering first-line options including antimicrobial therapy and/or antitoxin therapy.
For recurrent infection, the guidelines recommend FMT in patients who have had at least 2 recurrences, or patients with one recurrence and risk factors for further episodes (e.g., severe/complicated infection). FMT should used with caution in immunosuppressed patients.
These recommendations support US guidelines published earlier in the year by the Infectious Diseases Society of America/Society for Healthcare Epidemiology of America.See Management: approach
Updated guidelines on the diagnosis and management of Clostridium difficile infection (CDI) have been published by the Infectious Diseases Society of America/Society for Healthcare Epidemiology of America. Recommendations for the treatment of adults with CDI have been revised significantly. The guidelines state that:
A 10-day course of oral vancomycin or fidaxomicin should be used for the treatment of an initial episode of mild, moderate, or severe CDI, with metronidazole now reserved for non-severe infections in settings where access to first-line drugs is limited or cost is an issue. This recommendation is based on evidence that treatment with vancomycin or fidaxomicin results in greater cure rates and decreased risk of recurrence compared with metronidazole.
Recurrent infection should be treated with either a pulsed and tapered oral vancomycin regimen or a 10-day course of fidaxomicin depending on the drug used to treat the initial episode.
Faecal microbiota transplantation (FMT) is now recommended as an option in patients with at least 2 recurrences. This is based on recent evidence of higher cure rates with FMT compared with antibiotic therapy (70% to 80% for FMT compared with 45% to 50% for antibiotic therapy) and favourable short-term safety.
The updated guidance also reinforces the importance of good diagnostic stewardship by limiting stool testing for CDI to patients with unexplained, new-onset diarrhoea (defined as 3 or more unformed stools in 24 hours) who are not taking laxatives. In institutions that adopt this policy, nucleic acid amplification tests (NAATs) alone are an acceptable test for confirming the diagnosis. However, if there are no such policies in place, a testing algorithm (e.g., glutamate dehydrogenase [GDH] plus toxin; GDH plus toxin, arbitrated by NAAT; or NAAT plus toxin) is recommended.
A meta-analysis published in July 2018 by researchers in the UK found that fidaxomicin provides a sustained symptomatic cure most frequently compared to other treatment options, including vancomycin, and that there is little evidence to support the use of metronidazole as a first-line treatment.See Diagnosis: approach See Management: approach See Management: treatment algorithm
Patients usually present with diarrhoea, abdominal pain, and leukocytosis, and a history of recent antibiotic use. Other common symptoms include fever, abdominal tenderness, and distension.
Testing should be limited to patients with unexplained, new-onset diarrhoea (defined as 3 or more unformed stools in 24 hours). Molecular testing alone or as part of a multistep algorithm is recommended depending on local institutional protocols. May be evidence of pseudomembranes on sigmoidoscopy or colonoscopy in some patients.
Treatment is to discontinue the inciting antimicrobial agent and start therapy with oral vancomycin or fidaxomicin. Surgery may be required in fulminant disease.
About 5% to 50% of treated patients have recurrence after discontinuation of therapy, but most respond to a second course of therapy. Faecal microbiota transplantation may be recommended in patients with multiple recurrences.
Infection of the colon caused by the bacteria Clostridium difficile . Characterised by inflammation of the colon and the formation of pseudomembranes. Occurs in patients whose normal bowel flora has been disrupted by recent antibiotic use. Also known as pseudomembranous colitis, CDI, or CDAD. This topic covers the diagnosis and management of adults only.
The US Clinical and Laboratory Standards Institute announced a nomenclature change of the species name from Clostridium difficile to Clostridioides difficile in 2018; however, this name change has not been widely adopted yet. 
This topic focuses on the diagnosis and management of C difficile infection in adults only.
Clinical Associate Professor of Medicine
Alabama Infectious Diseases Center
AH declares that he has no competing interests.
Department of Epidemiology
Division of General Medicine and Epidemiology
UNC at Chapel Hill
JA declares that he has no competing interests.
Department of Gastroenterology
John Radcliffe Hospital
SK declares that he has no competing interests.
Clinical Reader and Consultant Gastroenterologist
Norfolk and Norwich University Hospital
IB declares that he has no competing interests.
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