Key Points From the New Clostridium difficile Infection Guidelines

The new C. diff guidelines have officially dropped and there have been some major changes in regards to treatment. So here is a simple breakdown for all my fellow clinicians!

First here is a quick review of the difference between severe and non-severe C.diff infections:

Non-severe = Leukocytosis with WBC less than or equal to 15,000 cells/ml and/or serum creatinine <1.5 mg/dl

Severe = Leukocytosis with WBC greater than or equal to 15,000 cells/ml and/or serum creatinine >1.5 mg/dl

Guideline Recommendations

If a patient presents with an initial episode of NON-SEVERE  C. diff infection:

• Vancomycin 125 mg orally 4 times a day for 10 days OR
• Fidaxomicin 200 mg orally twice daily for 10 days
• Alternative: metronidazole 500 mg 3 times a day orally for 10 days (weak recommendation/ high quality evidence)

If a patient presents with an initial episode of severe C. diff infection:

• Vancomycin 125 mg orally 4 times a day for 10 days OR
• Fidaxomicin 200 mg orally twice daily for 10 days

If a patient presents with fulminant C. diff with signs of hypotension, shock, ileus or megacolon:

• Vancomycin 500 mg orally 4 times a day and metronidazole 500 mg IV every 8 hours (also consider rectal vancomycin if ileus is present)

For C. diff recurrences evidence is still low, however for a first recurrence it is recommended to use a tapered or pulsed vancomycin regimen, an example of this is shown below:

1. Vancomycin 125 mg PO 4 times a day for 10-14 days THEN
2. 2 times a day for 1 week THEN
3. Once daily for 1 week THEN
4. Every 2-3 days for 2-8 weeks

or just simply revert to fidaxomicin if it has not been used before. There is strong evidence however in using fecal microbiota transplantation in patients who have a second recurrence of C.diff.

Role of Proton Pump Inhibitors (PPI’s)

• The guidelines simply state that unnecessary use of PPI’s should be discontinued, however there is weak evidence for discontinuation of PPI’s as a measure of preventing C. diff infections.

Infection Prevention and Control Recommendations

• Patients with C. diff infections should be kept in a private room with a dedicated toilet, if cohorting is required only cohort patients infected with the same organisms
• Gloves and gowns should be used upon entry to a room of a patient with C.diff infection
• Contact precautions should continue for at least 48 hours after diarrhea is resolved
• Hand hygiene should be performed before and after contact with a patient infected by C. diff with either soap and water OR alcohol-based hand hygiene
  • Hand washing is preferred if there is direct contact with feces or an area of fecal contamination

In general, one big change is the fact that fidaxomicin is now considered as a first line agent which is a big deal! I actually have a unique case that will soon be published in AJHP about how fidaxomicin caused pancytopenia in a patient which I cannot wait to share with you all once it is published.

— Ms Rx Geek