IDSA/SHEA recommends fidaxomicin rather than vancomycin for treatment of initial and recurrent episodes
The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) have published new evidence-based guidelines on the management of Clostridium difficile infection.
This focused update of the previous guideline (published in 2018) includes three new updated recommendations on suggested treatments for patients with initial and recurrent episodes based on available new data.
IDSA/SHEA now recommends using fidaxomicin rather than a standard course of vancomycin for the treatment of an initial episode, based on moderate-certainty evidence. The recommendation places high value in the beneficial effects and safety of fidaxomicin, but acknowledges that its use depends upon resources as fidaxomicin is not widely available and is more costly compared to vancomycin. Vancomycin remains an acceptable alternative in these patients.
The guideline also now recommends using a standard or extended-pulsed regimen of fidaxomicin rather than a standard course of vancomycin for the treatment of a first recurrent episode, based on low-certainty evidence. Vancomycin in a tapered and pulsed regimen or as a standard course remains an acceptable alternative in these patients.
Finally, the guideline recommends that bezlotoxumab, a monoclonal antibody targeting toxin B produced by C difficile, may be used alongside standard of care antibiotics for the prevention of recurrence in patients who have had a recurrent episode in the last 6 months, particularly those who are at high risk of recurrence.
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Clostridium difficile-associated disease usually presents with diarrhea, 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 diarrhea (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 fidaxomicin or vancomycin (metronidazole may be used in some locations). Surgery may be required in fulminant disease. Fecal microbiota transplantation is an option in severe and fulminant disease.
Up to half of treated patients have recurrence after discontinuation of therapy but most respond to a second course of therapy. Fecal microbiota transplantation is recommended in patients with multiple recurrences.
Infection of the colon caused by the bacteria Clostridium difficile. Characterized 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.
History and exam
- antibiotic exposure
- advanced age
- hospitalization or residence in a nursing home
- exposure to infected family member
- 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
- vitamin D deficiency
Ali Hassoun, MD, FACP, FIDSA, AAHIVS
Clinical Associate Professor of Medicine
Alabama Infectious Diseases Center
AH declares that he has no competing interests.
Julius Atashili, MD, MPH
Department of Epidemiology
Division of General Medicine and Epidemiology
UNC at Chapel Hill
JA declares that he has no competing interests.
Satish Keshav, MBBCh, DPhil, FRCP
Department of Gastroenterology
John Radcliffe Hospital
SK declares that he has no competing interests.
Ian Beales, MD, FRCP
Clinical Reader and Consultant Gastroenterologist
Norfolk and Norwich University Hospital
IB declares that he has no competing interests.
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