-
Severe CDI (WBC ≥15k or Cr >1.5)
Fulminant (pt w/ hypotension, shock, ileus or megacolon) D/c precipitating antibiotic, fluid resuscitate;1 high-dose vancomycin recommended in almost all situations; additional tx may be consideredD/c precipitating antibiotic, fluid resuscitate;1 high-dose vancomycin recommended in almost all situations; additional tx may be considered - Start high-dose PO/NG vancomycin, at least first 48-72h, per ACG;2 AAP recommends lower dose in children w/o abd distention3
- Combine w/ IV metronidazole, per IDSA, AAP; may be more beneficial in pts w/ ileus1,4
- If ileus, consider adding vancomycin retention enemas1,4-6
- Consider adding bezlotoxumab to SOC abx in adults;7 per ACG, reserve for pts ≥65 yo8
- Individualize decision to withhold/continue/increase immunosuppression in IBD pts, per AGA,5 though ACG recommends against holding immunosuppressants;1 may be reasonable to start steroids or ↑ immunosuppression after a few days of abx if no improvement1,5
- Avoid antimotility agents in untreated CDI, but they can be used safely on an as-needed basis after anti-CDI tx initiated1
- Don’t stop antisecretory tx, provided appropriate indication1
- Don’t use fidaxomicin, IVIg or antimotility agents in fulminant dz, per ACG1
- Consider FMT: IBD pts w/recurrence,1,5 pts w/ multiple recurrences1,9 & those who don’t improve on abx (esp if poor surgical candidates)1
- If surgical mgmt req’d, subtotal colectomy w/ rectal preservation preferred, per IDSA;9 ACG suggests total colectomy w/ ileostomy and stapled rectal stump;1 both suggest diverting loop ileostomy w/ colonic lavage & intraluminal vancomycin as alt option
Recommended tx options:1,4-6,9 View epocrates drug info: Footnotes 1 ACG 2021. Kelly CR, et al. ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections. Am J Gastroenterol. 2021. June 1;116(6):1124-1147. Accessed 8/16/21
2 ACG 2021. Use high-dose for first 48-72h. If improved, ↓dose to 125 mg q6h, continue for 10 additional days.
3 AAP 2021. In the absence of abd distention, AAP recommends max dose of 125 mg.
American Academy of Pediatrics. Committee on Infectious Diseases. Red Book: Report of the Committee on Infectious Diseases. Elk Grove Village, IL. American Academy of Pediatrics, 2021. Accessed 8/17/21
4 IDSA 2021. Johnson S, et al. Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults. Accessed 8/16/21
5 AGA 2017. Khanna S, et al. Management of Clostridium difficile infection in Inflammatory Bowel Disease: Expert Review from the Clinical Practice Updates Committee of the AGA Institute. Clin Gastroenterol Hepatol. 2017. Apr;15(4):607. Accessed 8/16/21
6 AAP 2021. American Academy of Pediatrics. Committee on Infectious Diseases. Red Book: Report of the Committee on Infectious Diseases. Elk Grove Village, IL. American Academy of Pediatrics, 2021. Accessed 8/17/21
7 IDSA 2021. Consider bezlotoxumab in pts w/ 2nd episode of CDI w/in 6mo; may be beneficial in 1st episode in pts w/ risk factors for recurrence: age ≥65 yo, immunocompromise, or severe CDI on presentation; may be more beneficial in those w/ multiple risk factors.
8 ACG 2021. Consider bezlotoxumab in pts ≥65 yo w/ at least 1 add’l risk factor: 2nd episode of CDI w/in 6mo, immunocompromised, or severe CDI.
Use w/ caution in CHF pts.
9 IDSA 2017. McDonald LC, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018. March 19;66(7):e1-e48. Free full-text article PDF @ PubMed® Central
10 IDSA 2017. Metronidazole optional in children w/ fulminant dz, per IDSA.
D/c precipitating antibiotic; fidaxomicin now preferred in adults by IDSA, but vancomycin remains an option; additional tx may be considered - Use fidaxomicin over vancomycin in adults, per IDSA;1 both are options per ACG, but not in pregnancy, breastfeeding,2 or children3
- In IBD, vancomycin preferred (AGA: 10 days, ACG: 14 days),2,4 though AGA suggests fidaxomicin as option5
- If using vancomycin, consider tapered/pulsed dosing regimen in setting of recurrent CDI in adults;6 standard dosing preferred in all children w/ severe CDI3
- Consider adding bezlotoxumab to SOC abx in adults;7 per ACG, reserve for pts ≥65 yo8
- Avoid antimotility agents in untreated CDI, but they can be used safely on an as-needed basis after anti-CDI tx initiated2
- Individualize decision to withhold/continue/increase immunosuppression in IBD pts, per AGA,4 though ACG recommends against holding immunosuppressants;2 may be reasonable to start steroids or ↑ immunosuppression after a few days of abx if no improvement2,4
- Don’t stop antisecretory tx, provided appropriate indication2
- Consider FMT: IBD pts w/ recurrence,2,4 pts w/ multiple recurrences2,9 & those who don’t improve2
Recommended tx options:1-3,9 View epocrates drug info: Footnotes 1 IDSA 2021. Johnson S, et al. Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults. Accessed 8/16/21
2 ACG 2021. Kelly CR, et al. ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections. Am J Gastroenterol. 2021. June 1;116(6):1124-1147. Accessed 8/16/21
3 AAP 2021. American Academy of Pediatrics. Committee on Infectious Diseases. Red Book: Report of the Committee on Infectious Diseases. Elk Grove Village, IL. American Academy of Pediatrics, 2021. Accessed 8/17/21
4 AGA 2017. Khanna S, et al. Management of Clostridium difficile infection in Inflammatory Bowel Disease: Expert Review from the Clinical Practice Updates Committee of the AGA Institute. Clin Gastroenterol Hepatol. 2017. Apr;15(4):607. Accessed 8/16/21
5 AGA 2017.
AGA defines “severe-complicated CDI” as: ICU admit, hypotension, T>38.5°C, ileus/megacolon, AMS, WBC >35k or <2k, or lactate >2.2 mmol/L.
In severe-complicated CDI, vancomycin 500 mg PO q6h plus metronidazole 500 mg IV q8h is recommended (w/ PR vancomycin, if ileus present).
In absence of severe-complicated criteria, vancomycin 125 mg PO q6h is recommended, though fidaxomicin 200 mg PO q12h can be considered.
6 IDSA 2021. Tapered/pulsed vancomycin regimen example: 125 mg PO qid x10-14 days, then bid x7 days, then every 2-3 days x2-8wk.
7 IDSA 2021. Consider bezlotoxumab in pts w/ 2nd episode of CDI w/in 6mo; may be beneficial in 1st episode in pts w/ risk factors for recurrence: age ≥65 yo, immunocompromise, or severe CDI on presentation; may be more beneficial in those w/ multiple risk factors.
Data when combined w/ fidaxomicin are limited. Use w/ caution in CHF pts.
8 ACG 2021. Consider bezlotoxumab in pts ≥65 yo w/ at least 1 add’l risk factor: 2nd episode of CDI w/in 6mo, immunocompromised, or severe CDI.
9 IDSA 2017. McDonald LC, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018. March 19;66(7):e1-e48. Free full-text article PDF @ PubMed® Central
10 AAP 2021. Tapered/pulsed vancomycin regimen examples:
• vancomycin 10 mg/kg/dose (max 125 mg/dose) PO qid x7 days, then tid x7 days, then bid x7 days, then qd x7 days, then qod x7 days, then q72h x7 days
• vancomycin 10 mg/kg/dose (max 125 mg/dose) PO qid x14 days, then bid x7-14 days, then qd x7-14 days, then q48-72h x2-8wk
11 AAP 2021. Rifaximin dosing in peds pts is not well described; it is poorly water-soluble and minimally absorbed, and should be avoided if the pt recently received rifaximin for CDI or another indication.
12 AAP 2021. Nitazoxanide dosing by age:
1-3 yo: 100 mg PO bid
4-11 yo: 200 mg PO bid
12+ yo: 500 mg PO bid
-
D/c precipitating antibiotic; fidaxomicin now preferred in adults by IDSA, but vancomycin remains an option; additional tx may be considered - Use fidaxomicin over vancomycin in adults, per IDSA;1 both are options per ACG, but not in pregnancy, breastfeeding,2 or children3
- In IBD, vancomycin preferred (AGA: 10 days, ACG: 14 days),2,4 though AGA suggests fidaxomicin as option
- In children, metronidazole recommended as initial agent by AAP,3 but vancomycin also 1st line, per IDSA5
- Consider adding bezlotoxumab to SOC abx in adults ≥65 yo or immunocompromised;6 per ACG, reserve for pts who are both age ≥65 yo & immunocompromised7
- Avoid antimotility agents in untreated CDI, but they can be used safely on an as-needed basis after anti-CDI tx initiated2
- Individualize decision to withhold/continue/increase immunosuppression in IBD pts, per AGA,4 though ACG recommends against holding immunosuppressants;2 may be reasonable to start steroids or ↑ immunosuppression after a few days of abx if no improvement2,4
- Don’t recommend probiotics for prevention of recurrence2
- Don’t stop antisecretory tx, provided appropriate indication2
- Don’t use rifaximin2
Recommended tx options:1-3,5 View epocrates drug info: Footnotes 1 IDSA 2021. Johnson S, et al. Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults. Accessed 8/16/21
2 ACG 2021. Kelly CR, et al. ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections. Am J Gastroenterol. 2021. June 1;116(6):1124-1147. Accessed 8/16/21
3 AAP 2021. American Academy of Pediatrics. Committee on Infectious Diseases. Red Book: Report of the Committee on Infectious Diseases. Elk Grove Village, IL. American Academy of Pediatrics, 2021. Accessed 8/17/21
4 AGA 2017. Khanna S, et al. Management of Clostridium difficile infection in Inflammatory Bowel Disease: Expert Review from the Clinical Practice Updates Committee of the AGA Institute. Clin Gastroenterol Hepatol. 2017. Apr;15(4):607. Accessed 8/16/21
5 IDSA 2017. McDonald LC, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018. March 19;66(7):e1-e48. Free full-text article PDF @ PubMed® Central
6 IDSA 2021. Bezlotoxumab may be beneficial in 1st episode in pts w/ risk factors for recurrence: age ≥65 yo, immunocompromise, or severe CDI on presentation; may be more beneficial in those w/ multiple risk factors.
Data when combined w/ fidaxomicin are limited. Use w/ caution in CHF pts.
7 ACG 2021. Consider bezlotoxumab in pts ≥65 yo w/ at least 1 add’l risk factor: 2nd episode of CDI w/in 6mo, immunocompromised, or severe CDI.
8 ACG 2021. ACG recommends metronidazole only for low-risk pts (younger outpts w/ minimal comorbidities), particularly in cost-sensitive environments. They also only recommend vancomycin or fidaxomicin in immunocompromised pts.
9 IDSA 2017. For children, IDSA recommends:
metronidazole 7.5 mg/kg/dose (max 500 mg/dose) PO tid or qid
OR
vancomycin 10 mg/kg/dose (max 125 mg/dose) PO qid
10 AAP 2021. If failure to respond in 5-7 days, consider switch to vancomycin 40 mg/kg/day (max 125 mg/dose) PO q6h x10 days.
D/c precipitating antibiotic; fidaxomicin now preferred in adults by IDSA, but vancomycin remains an option; consider bezlotoxumab if CDI recurred w/in 6mo of last episode & in certain other pts; consider FMT in IBD pts - Use fidaxomicin over vancomycin in adults, per IDSA;1 both are options per ACG, but not in pregnancy, breastfeeding,2 or children3
- In IBD, vancomycin preferred, per ACG,2 though AGA suggests fidaxomicin as option4
- In children, metronidazole recommended as initial agent by AAP,3 but vancomycin also 1st line, per IDSA5
- Consider adding bezlotoxumab to SOC abx in adults if recurrence w/in 6mo, or if ≥65 yo or immunocompromised;6 per ACG, reserve for pts who recurred w/in 6mo, but also for those both age ≥65 yo & immunocompromised7
- Avoid antimotility agents in untreated CDI, but they can be used safely on an as-needed basis after anti-CDI tx initiated2
- Individualize decision to withhold/continue/increase immunosuppression in IBD pts per AGA,4 though ACG recommends against holding immunosuppressants;2 may be reasonable to start steroids or ↑ immunosuppression after a few days of abx if no improvement2,4
- Don’t recommend probiotics for prevention of recurrence2
- Don’t stop antisecretory tx, provided appropriate indication2
- Consider FMT: IBD pts4 & those who recur w/in 8wk of previous FMT2
Recommended tx options:1-3,5 View epocrates drug info: Footnotes 1 IDSA 2021. Johnson S, et al. Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults. Accessed 8/16/21
2 ACG 2021. Kelly CR, et al. ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections. Am J Gastroenterol. 2021. June 1;116(6):1124-1147. Accessed 8/16/21
3 AAP 2021. American Academy of Pediatrics. Committee on Infectious Diseases. Red Book: Report of the Committee on Infectious Diseases. Elk Grove Village, IL. American Academy of Pediatrics, 2021. Accessed 8/17/21
4 AGA 2017. Khanna S, et al. Management of Clostridium difficile infection in Inflammatory Bowel Disease: Expert Review from the Clinical Practice Updates Committee of the AGA Institute. Clin Gastroenterol Hepatol. 2017. Apr;15(4):607. Accessed 8/16/21
5 IDSA 2017. McDonald LC, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018. March 19;66(7):e1-e48. Free full-text article PDF @ PubMed® Central
6 IDSA 2021. Consider bezlotoxumab in pts w/ 2nd episode of CDI w/in 6mo; may be beneficial in 1st episode in pts w/ risk factors for recurrence: age ≥65 yo, immunocompromise, or severe CDI on presentation; may be more beneficial in those w/ multiple risk factors.
Data when combined w/ fidaxomicin are limited. Use w/ caution in CHF pts.
7 ACG 2021. Consider bezlotoxumab in pts ≥65 yo with at least 1 add’l risk factor: 2nd episode of CDI w/in 6mo, immunocompromised, or severe CDI.
8 ACG 2021. Fidaxomicin suggested for 1st recurrence after initial course of vancomycin or metronidazole.
9 IDSA 2021. Tapered/pulsed vancomycin regimen example: 125 mg PO qid x10-14 days, then bid x7 days, then every 2-3 days x2-8wk.
10 ACG 2021. Tapered/pulsed vancomycin suggested for 1st recurrence after initial course of fidaxomicin, vancomycin, or metronidazole.
11 IDSA 2021. Consider standard course of vancomycin if metronidazole was used for tx of 1st episode.
12 IDSA 2017. For children, IDSA recommends:
metronidazole 7.5 mg/kg/dose (max 500 mg/dose) PO tid or qid
OR
vancomycin 10 mg/kg/dose (max 125 mg/dose) PO qid
13 AAP 2021. If failure to respond in 5-7 days, consider switch to vancomycin 40 mg/kg/day (max 125 mg/dose) PO q6h x10 days.
Second/subsequent CDI recurrence D/c precipitating antibiotic; use fidaxomicin or vancomycin (+/- rifaximin) in adults, but vancomycin (+/- rifaximin) is only abx option in children; consider bezlotoxumab if CDI recurred w/in 6mo of last episode & in certain other pts; consider FMT for all w/ multi-recurrent CDI - Use fidaxomicin or vancomycin (tapered/pulsed dose or in combo w/ rifaximin in adults, per IDSA1
- Vancomycin only option in pregnancy, breastfeeding,2 & children3
- In IBD, vancomycin preferred, per ACG,2 though AGA also suggests fidaxomicin
- Consider adding bezlotoxumab to SOC abx in adults if recurrence w/in 6mo, or if ≥65 yo or immunocompromised;4 per ACG, reserve for pts who recurred w/in 6mo, but also for those both age ≥65 yo & immunocompromised5
- Avoid antimotility agents in untreated CDI, but they can be used safely on an as-needed basis after anti-CDI tx initiated2
- Individualize decision to withhold/continue/increase immunosuppression in IBD pts, per AGA,6 though ACG recommends against holding immunosuppressants;2 may be reasonable to start steroids or ↑ immunosuppression after a few days of abx if no improvement2,6
- Consider FMT in all adults w/ multiple recurrences 2,6 (3+, per IDSA);1,7 AAP suggests FMT for children w/ 3rd recurrence3
- If pt not a candidate for FMT, relapsed after FMT or requires ongoing/frequent abx, consider suppressive PO vancomycin8
- Don’t recommend probiotics for prevention of recurrence2
- Don’t stop antisecretory tx, provided appropriate indication2
Recommended tx options:1-3,7 View epocrates drug info: Footnotes 1 IDSA 2021. Johnson S, et al. Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults. Accessed 8/16/21
2 ACG 2021. Kelly CR, et al. ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections. Am J Gastroenterol. 2021. June 1;116(6):1124-1147. Accessed 8/16/21
3 AAP 2021. American Academy of Pediatrics. Committee on Infectious Diseases. Red Book: Report of the Committee on Infectious Diseases. Elk Grove Village, IL. American Academy of Pediatrics, 2021. Accessed 8/17/21
4 IDSA 2021. Consider bezlotoxumab in pts w/ 2nd episode of CDI w/in 6mo; may be beneficial in 1st episode in pts w/ risk factors for recurrence: age ≥65 yo, immunocompromise, or severe CDI on presentation; may be more beneficial in those w/ multiple risk factors.
Data when combined w/ fidaxomicin are limited. Use w/ caution in CHF pts.
5 ACG 2021. Consider bezlotoxumab in pts ≥65 yo w/ at least 1 add’l risk factor: 2nd episode of CDI w/in 6mo, immunocompromised, or severe CDI.
6 AGA 2017. Khanna S, et al. Management of Clostridium difficile infection in Inflammatory Bowel Disease: Expert Review from the Clinical Practice Updates Committee of the AGA Institute. Clin Gastroenterol Hepatol. 2017. Apr;15(4):607. Accessed 8/16/21
7 IDSA 2017. McDonald LC, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018. March 19;66(7):e1-e48. Free full-text article PDF @ PubMed® Central
8 ACG 2021. Suppressive dosing: vancomycin 125 mg PO qd.
9 IDSA 2021. Tapered/pulsed vancomycin regimen example: 125 mg PO qid x10-14 days, then bid x7 days, then every 2-3 days x2-8wk.
10 AAP 2021. Tapered/pulsed vancomycin regimen examples:
• vancomycin 10 mg/kg/dose (max 125 mg/dose) PO qid x7 days, then tid x7 days, then bid x7 days, then qd x7 days, then qod x7 days, then q72h x7 days
• vancomycin 10 mg/kg/dose (max 125 mg/dose) PO qid x14 days, then bid x7-14 days, then qd x7-14 days, then q48-72h x2-8wk
11 IDSA 2017. IDSA recommends 10 days of vancomycin followed by 20 days of rifaximin. Nitazoxide not included in recs.
12 AAP 2021. Rifaximin dosing in peds pts is not well described; it is poorly water-soluble and minimally absorbed, and should be avoided if the pt recently received rifaximin for CDI or another indication.
13 AAP 2021. Nitazoxanide dosing by age:
1-3 yo: 100 mg PO bid
4-11 yo: 200 mg PO bid
12+ yo: 500 mg PO bid
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