Treatment of C. difficile Infection

Immediate Management

The American College of Gastroenterology recommends immediately discontinuing both proton pump inhibitors and H2 blockers, as they are strongly associated with increased risk of C. difficile infection and recurrence, with an odds ratio of 2.5 for CDI development and a 42% increased risk of recurrence when continued during treatment 2
Discontinue unneeded PPIs through stewardship activities in all patients at high risk for CDI, with a strong recommendation and high quality evidence 3, 2

The Infectious Diseases Society of America recommends oral vancomycin 125 mg four times daily for 10 days or fidaxomicin 200 mg twice daily for 10 days as first-line therapy for non-severe CDI, with a strong recommendation and high quality evidence 1
For severe CDI, oral vancomycin 125 mg four times daily for 10 days is recommended, with a strong recommendation and high quality evidence, and has demonstrated a 97% cure rate versus 76% for metronidazole in severe disease 1

The Society for Healthcare Epidemiology of America recommends stopping all non-CDI antibiotics immediately if clinically feasible, and using agents less frequently implicated with CDI if continued antibiotic therapy is required for another infection 3, 1
Avoid using antiperistaltic agents or opiates, as they worsen outcomes, with a strong recommendation and high quality evidence 1
Monitor treatment response by 72 hours, and escalate therapy rather than continuing ineffective treatment if no improvement by day 3-5, with a strong recommendation and high quality evidence 1

The American College of Gastroenterology recommends against testing for C. difficile after completing treatment, and only testing symptomatic patients, with a strong recommendation and high quality evidence 1
For fulminant CDI, high-dose oral vancomycin 500 mg four times daily PLUS IV metronidazole 500 mg every 8 hours is recommended, with a strong recommendation and high quality evidence 1