What is the treatment for Clostridioides difficile (C. diff) infection?

Treatment of Clostridioides difficile Infection

For C. difficile infection (CDI), oral vancomycin (125 mg four times daily for 10 days) is the recommended first-line treatment, with treatment choice based on disease severity and risk of recurrence. 1

Treatment Algorithm Based on Disease Severity

Initial Episode Treatment

• Non-severe CDI:

  • First-line: Oral vancomycin 125 mg four times daily for 10 days 1
  • Alternative: Fidaxomicin 200 mg twice daily for 10 days 1, 2
  • Note: Metronidazole is no longer recommended as first-line therapy for adults 1, 3

• Severe CDI:

  • Oral vancomycin 125 mg four times daily for 10 days 1
  • Fidaxomicin 200 mg twice daily for 10 days may be preferred due to lower recurrence rates 1, 2

• Fulminant CDI:

  • Intravenous metronidazole 500 mg three times daily PLUS
  • Oral vancomycin 500 mg four times daily (or intracolonic vancomycin 500 mg in 100 mL normal saline every 4-12 hours if ileus present) 1
  • Prompt surgical consultation is strongly recommended 1

Recurrent CDI Treatment

• First Recurrence:

  • Fidaxomicin 200 mg twice daily for 10 days (preferred due to lower recurrence risk) 1
  • Alternative: Extended-pulsed fidaxomicin regimen (days 1-5: 200 mg twice daily, days 6-25: 200 mg once every other day) 1
  • Alternative: Vancomycin taper/pulse regimen (125 mg four times daily for 10-14 days, then twice daily for 7 days, then once daily for 7 days, then every 2-3 days for 2-8 weeks) 1

• Multiple Recurrences:

  • Fecal Microbiota Transplantation (FMT) is strongly recommended after two or more recurrences 1, 4, 5, 6
  • Success rates of 80-90% in preventing further recurrences 1

Special Considerations

Pediatric Dosing

• Children 6 months and older:
  • Vancomycin: 10 mg/kg/dose (max 125 mg) four times daily 1
  • Fidaxomicin: Approved for children 6 months and older 2

Elderly Patients

• Oral vancomycin is preferred as first-line treatment due to superior efficacy compared to metronidazole 1
• Higher risk for CDI-related morbidity, mortality, and recurrence 1
• Consider FMT for elderly patients with recurrent CDI who may not tolerate surgical intervention 4

Surgical Intervention

Surgery should be considered in the following situations:

• Perforation of the colon
• Systemic inflammation with deteriorating clinical condition despite antibiotic therapy
• Toxic megacolon
• Severe ileus
• Surgery should be performed before serum lactate exceeds 5.0 mmol/L 1

Prevention Strategies

• Stop unnecessary antibiotics as soon as possible 1
• Isolate patients with suspected CDI 1
• Avoid antiperistaltic agents and opiates, especially in acute settings 1
• Hand hygiene with soap and water (preferred during outbreaks) 1
• Environmental cleaning with sporicidal agents 1
• Implement antibiotic stewardship programs 1

Diagnostic Approach

• Test only symptomatic patients with ≥3 unformed stools in 24 hours 1
• Optimal testing: Initial screening with NAAT or GDH assay, followed by toxin A/B detection for positive screens 1

Common Pitfalls to Avoid

1. Using metronidazole as first-line therapy (no longer recommended for adults) 1, 3
2. Testing asymptomatic patients or those taking laxatives 1
3. Failure to discontinue the inciting antibiotic when possible 1
4. Delaying surgical consultation in fulminant cases 1
5. Not considering FMT for patients with multiple recurrences 1, 4, 5
6. Using antibiotics for CDI prophylaxis (not recommended) 1
7. Failing to monitor patients for at least 8 weeks after treatment to assess for recurrence 1