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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Summary
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
- 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
Diagnostic investigations
1st investigations to order
- CBC
- 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
Treatment algorithm
Contributors
Authors
Ali Hassoun, MD, FACP, FIDSA, AAHIVS
Clinical Associate Professor of Medicine
Alabama Infectious Diseases Center
Huntsville
AL
Disclosures
AH declares that he has no competing interests.
Peer reviewers
Julius Atashili, MD, MPH
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.
Satish Keshav, MBBCh, DPhil, FRCP
Consultant Gastroenterologist
Department of Gastroenterology
John Radcliffe Hospital
Oxford
UK
Disclosures
SK declares that he has no competing interests.
Ian Beales, MD, FRCP
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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