The key new guideline recommendations for the treatment of Clostridioides difficile infection (CDI) vary according to the severity of the disease and the specific patient context.
Non-severe disease
- The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) 2021 guidelines suggest administering fidaxomicin 200 mg PO BID for 10 days rather than a standard course of vancomycin in patients with an initial episode of CDI
- The American College of Gastroenterology (ACG) 2021 guidelines recommend oral fidaxomicin 200 mg BID or oral vancomycin 125 mg QID for 10 days in patients with an initial episode of non-severe CDI
- The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) 2021 guidelines recommend administering oral metronidazole 500 mg three times daily for 10 days only when vancomycin and fidaxomicin are not available or feasible
Severe disease
- The IDSA/SHEA 2021 guidelines suggest administering fidaxomicin 200 mg PO BID for 10 days rather than a standard course of vancomycin in patients with an initial episode of CDI
- The ACG 2021 guidelines recommend administering vancomycin 125 mg QID or fidaxomicin 200 mg BID for 10 days as initial therapy in patients with severe CDI
- The ESCMID 2021 guidelines recommend administering vancomycin 125 mg QID for 10 days or fidaxomicin 200 mg BID for 10 days in patients with severe CDI
Fulminant disease
- The IDSA/SHEA 2018 guidelines recommend administering IV metronidazole 500 mg every 8 hours in addition to oral or rectal vancomycin, particularly in patients with ileus
- The ACG 2021 guidelines recommend administering oral vancomycin 500 mg every 6 hours in patients with fulminant CDI. Combination therapy with parenteral metronidazole 500 mg every 8 hours is also considered
Management of recurrence
- The ESCMID 2021 guidelines recommend administering bezlotoxumab in addition to standard-of-care antibiotic treatment or performing fecal microbiota transplantation after standard-of-care antibiotic pretreatment for a second or further CDI recurrence, depending on patient characteristics, previous treatment, local regulations, availability, and feasibility
- The American Society of Colon and Rectal Surgeons (ASCRS) 2021 guidelines suggest offering adjunctive agents, including other antimicrobials, binding agents, and probiotics, in addition to standard treatment in patients with recurrent or refractory CDI
In summary, the treatment of Clostridioides difficile infection has evolved, with many guidelines now recommending fidaxomicin as a first-line therapy for both non-severe and severe CDI. Vancomycin remains a recommended option, especially when fidaxomicin is not available. For fulminant CDI, high-dose vancomycin combined with intravenous metronidazole is advised. The management of recurrent CDI includes newer interventions such as bezlotoxumab and fecal microbiota transplantation, tailored to patient-specific factors and resource availability.