US guidance recommends vancomycin or fidaxomicin first line for adults with C difficile infection
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:
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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 nonsevere 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.
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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.
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Fecal 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 favorable 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 diarrhea (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 algorithmSummary
Definition
History and exam
Other diagnostic factors
- fever
- abdominal tenderness
- nausea and vomiting
- abdominal distension
- symptoms of shock
Risk factors
- antibiotic exposure
- advanced age
- hospitalization or residence in a nursing home
- history of Clostridium difficile-associated disease
- use of acid-suppressing drugs
- inflammatory bowel disease
- solid organ transplant recipients
- hematopoietic stem cell transplant recipients
- chronic kidney disease
- HIV infection
- immunosuppressive agents or chemotherapy
- gastrointestinal surgery
Diagnostic investigations
1st investigations to order
- CBC
- stool guaiac (fecal occult blood test)
- stool PCR
- stool immunoassay for glutamate dehydrogenase
- stool immunoassay for toxins A and B
- abdominal x-ray
Investigations to consider
- cell culture cytotoxicity neutralization assay
- CT abdomen
- sigmoidoscopy or colonoscopy
Treatment algorithm
Contributors
Authors VIEW ALL
Clinical Associate Professor of Medicine
Alabama Infectious Diseases Center
Huntsville
AL
Disclosures
AH declares that he has no competing interests.
Peer reviewers VIEW ALL
Department of Epidemiology
Division of General Medicine and Epidemiology
UNC at Chapel Hill
Chapel Hill
NC
Disclosures
JA declares that he has no competing interests.
Consultant Gastroenterologist
Department of Gastroenterology
John Radcliffe Hospital
Oxford
UK
Disclosures
SK declares that he has no competing interests.
Clinical Reader and Consultant Gastroenterologist
Norfolk and Norwich University Hospital
Norwich
UK
Disclosures
IB declares that he has no competing interests.
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