When should patients with Clostridioides difficile (C-diff) be referred to a Gastroenterology (GI) specialist?

When to Refer C. difficile Patients to Gastroenterology

Patients with severe or fulminant C. difficile infection not responding to standard antibiotics within 2-5 days, those with recurrent CDI requiring fecal microbiota transplant, and any patient with fulminant disease (shock, ileus, or megacolon) should be referred to gastroenterology as part of mandatory multidisciplinary care. 1

Mandatory GI Referral Situations

Severe or Fulminant CDI Requiring Multidisciplinary Management

• All patients with severe or fulminant CDI require multidisciplinary care including gastroenterology, critical care, surgery, and infectious disease. 1

• Severe CDI is defined as leukocyte count ≥15 × 10⁹ cells/L and/or creatinine ≥1.5 mg/dL. 1

• Fulminant CDI presents as severe disease with shock, ileus, or megacolon. 1

• GI consultation should occur when patients fail to respond to standard antibiotic therapy within 2-5 days of initiating treatment. 1

Recurrent CDI Requiring Advanced Therapies

• Patients with recurrent CDI who are candidates for fecal microbiota transplant should be referred to gastroenterology. 1, 2

• FMT is typically considered after the second recurrence (third episode) or in select high-risk patients. 2

• Gastroenterologists perform colonoscopic or flexible sigmoidoscopic FMT, which is the preferred route for initial administration in severe cases. 1

GI Involvement for Procedural Interventions

FMT Administration

• The first dose of FMT should be delivered via colonoscopy or flexible sigmoidoscopy, procedures performed by gastroenterologists. 1

• Colonoscopy allows confirmation of diagnosis and determination of CDI severity through direct visualization. 1

• Most patients with severe or fulminant CDI will need repeat FMT every 3-5 days based on treatment response, requiring ongoing GI involvement. 1

Follow-up After FMT

• Treatment response is assessed by monitoring stool output, white blood cell count, and C-reactive protein, with gastroenterology coordinating repeat procedures as needed. 1

• After resolution of colitis, a final fecal microbiota-based therapy should be performed as an outpatient to prevent recurrence, which can be administered via colonoscopy, capsule, or enema. 1

Special Populations Requiring GI Consultation

Inflammatory Bowel Disease Patients

• Patients with IBD and CDI are at higher risk of mortality and colectomy, requiring gastroenterology involvement to differentiate CDI from IBD flare and coordinate treatment. 1

• The complex nature of dysbiosis and colitis in IBD makes accurate CDI diagnosis versus colonization challenging, necessitating specialist input. 1

Immunocompromised Patients

• Mildly or moderately immunocompromised patients with recurrent CDI may benefit from GI consultation for consideration of fecal microbiota-based therapies. 1

• Severely immunocompromised patients (active cytotoxic therapy, neutropenia, CAR-T therapy, untreated HIV with CD4 <200) should not receive fecal microbiota-based therapies but may still require GI consultation for management guidance. 1

When GI Referral May Not Be Immediately Necessary

First Episode, Non-Severe CDI

• Initial episodes of non-severe CDI can typically be managed by primary care or hospitalists with oral vancomycin or fidaxomicin without immediate GI referral. 2, 3

• Standard antibiotic therapy is effective in most first episodes, with clinical response expected within 3-5 days. 4

First Recurrence with Standard Options Available

• A first recurrence can be managed with vancomycin taper, tapered-pulsed fidaxomicin, or bezlotoxumab without mandatory GI consultation. 2

• However, GI referral should be considered if standard approaches fail or if the patient is at high risk for further recurrences. 2

Critical Pitfalls to Avoid

• Do not delay GI consultation in severe or fulminant cases—these are medical emergencies requiring immediate multidisciplinary involvement. 1

• FMT is not advised in patients with bowel perforation or obstruction, and surgical consultation takes precedence in these situations. 1

• Administration of FMT via nasoenteric tube is discouraged due to increased risk of fecal aspiration. 1

• Patients requiring frequent or long-term antibiotics may have diminished efficacy from fecal microbiota-based therapies and need careful GI evaluation before proceeding. 2