Clostridioides 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 as an alternative option in certain patients and some locations). Surgery may be required in fulminant disease. Fecal microbiota transplantation is an option in severe and fulminant disease, and recurrent infections.
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. Bezlotoxumab may be considered in patients at high risk of recurrence.
Infection of the colon caused by the bacteria Clostridioides difficile (formerly known as 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.
The US Clinical and Laboratory Standards Institute announced a nomenclature change of the species name from Clostridium difficile to Clostridioides difficile in 2018.
This topic focuses on the diagnosis and management of C difficile infection in adults only.
History and exam
Key diagnostic factors
- abdominal pain
Other diagnostic factors
- abdominal tenderness
- nausea and vomiting
- abdominal distension
- symptoms of shock
- antibiotic exposure
- advanced age
- hospitalization or residence in a nursing home
- exposure to infected family member
- history of Clostridioides 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
1st investigations to order
- stool guaiac (fecal occult blood test)
- stool polymerase chain reaction (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
- stool lactoferrin or calprotectin
initial episode: nonsevere
initial episode: severe
initial episode: fulminant
- Antibiotic-associated diarrhea (AAD)
- Ischemic colitis
- Bacterial or viral gastroenteritis
- Management of Clostridioides difficile infection (CDI) in hematopoietic cell transplant patients
- Clostridioides difficile infection: antimicrobial prescribing NICE guideline [NG199]
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