Treatment of Clostridioides difficile Infection

Disease Severity Assessment and Treatment

The American College of Gastroenterology recommends oral vancomycin 125 mg four times daily for 10 days as the first-line treatment for patients with Clostridioides difficile infection (CDI) without prior antibiotic exposure, regardless of disease severity 1, 2
Non-severe CDI is characterized by stool frequency <4 times daily, WBC <15,000 cells/mL, serum creatinine <1.5 mg/dL, and no signs of severe colitis, and is treated with oral vancomycin 125 mg four times daily for 10 days 1, 3
Severe CDI is characterized by fever, rigors, hemodynamic instability, signs of peritonitis, ileus, marked leukocytosis (WBC ≥15,000 cells/mL), rise in serum creatinine (>1.5 mg/dL), elevated serum lactate, or pseudomembranous colitis on endoscopy, and is treated with oral vancomycin 125 mg four times daily for 10 days 1, 2

For non-severe CDI, the Infectious Diseases Society of America recommends oral vancomycin 125 mg four times daily for 10 days as the first-line treatment, with alternative options including oral metronidazole 500 mg three times daily for 10 days or oral fidaxomicin 200 mg twice daily for 10 days 1, 4, 5
For severe CDI, the Society for Healthcare Epidemiology of America recommends oral vancomycin 125 mg four times daily for 10 days as the first-line treatment, with alternative options including oral fidaxomicin 200 mg twice daily for 10 days 1, 4, 6

The American College of Emergency Physicians recommends early detection of shock and aggressive management of underlying organ dysfunction, as well as intravenous fluid resuscitation to correct volume depletion and electrolyte replacement 6, 2
The American College of Gastroenterology recommends considering albumin supplementation in patients with severe hypoalbuminemia (<2 g/dL) 6, 2

The Infectious Diseases Society of America recommends discontinuing unnecessary antibiotics if possible, as they can worsen CDI and increase recurrence risk, and avoiding antimotility agents such as loperamide and opiates, especially in the acute setting 7, 4, 3, 2
The Society for Healthcare Epidemiology of America recommends implementing strict handwashing with soap and water (alcohol does not inactivate C. difficile spores) and isolating patients with known or suspected CDI until resolution of diarrhea (formed stool for at least 48 hours) 2, 7

The American College of Gastroenterology recommends treating first recurrence with the same treatment as the initial episode, unless disease has progressed from non-severe to severe, and considering tapered/pulsed regimen for second or subsequent recurrences 5, 6, 1
The Infectious Diseases Society of America recommends considering fecal microbiota transplantation for multiple recurrences 7

The American College of Surgeons recommends considering colectomy in patients with perforation of the colon, systemic inflammation and deteriorating clinical condition not responding to antibiotic therapy, toxic megacolon or severe ileus, or serum lactate >5.0 mmol/L 5, 1