ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides Difficile Infection
Guideline Topline
The 2021 American College of Gastroenterology guidelines on management of C. difficile reflect an expanding body of evidence for preventing, diagnosing, and treating the dangerous infection.
A Patient Care Online Guideline Topline
New 2021 guidelines from the American College of Gastroenterology (ACG) on the management of Clostridioides difficile infection (CDI) include recommendations that draw on a range of developments from increased recognition of challenges in diagnosis to the availability of biologic agents and the growing body of evidence to support use of fecal microbiota transplantation (FMT) in recurrent infection and in inflammatory bowel disease (IBD).
The guidelines, published in June 2021 in The American Journal of Gastroenterology, complement newly revised guidelines from the Infectious Disease Society of America (IDSA) and Society of Healthcare Epidemiologists of America (SHEA), according to ACG guideline authors. While the ACG guidelines match categories of infection severity with IDSA/SHEA, ie, non-severe, severe, and fulminant, the new recommendations focus principally on evidence-based, clinically relevant recommendations for the diagnosis, management, and prevention of CDI. The new content expands on areas inducing distinguishing C. difficile colonization from active infection and evaluation and treatment of CDI in the setting of IBD.
Specific ACG recommendations follow in our Guideline Topline slide show summary.
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PREVENTION OF CDI. Probiotics for the prevention of C. difficile infection (CDI) should not be used in patients being treated with antibiotics or for the prevention of CDI Nor should probiotics be use for prevention of CDI recurrence (secondary prevention).
DIAGNOSIS OF CDI. Only individuals with symptoms suggestive
of active CDI should be tested (3 or more unformed stools in 24 hours). CDI testing algorithms should include both a highly sensitive and a highly specific testing modality to help distinguish colonization
from active infection.
CDI CLASSIFICATION: SEVERE, FULMINANT. Criteria predictive of unfavorable outcomes should be used to classify severe CDI at the time of diagnosis: White blood cell≥15 000 cells/mm3 or serum creatinine >1.5 mg/dL. Fulminant infection is defined in a patient
meeting criteria for severe CDI plus the presence of hypotension or shock or ileus or megacolon.
CDI TREATMENT: NON-SEVERE, INITIAL EPISODE.* Recommended. Oral vancomycin 125 mg 4x/day for 10 days or oral fidaxomicin 200 mg 2x/day for 10 days. Oral metronidazole 500 mg 3x/ day for 10 days may be considered for treatment of initial non-severe episode in low-risk patients.
CDI TREATMENT: SEVERE CDI, INITIAL TREATMENT. Recommended: Vancomycin 125 mg 4x/day for 10 days or fidaxomicin 200 mg 2x/day for 10 days.
TREATMENT: FULMINANT CDI: Recommended: Medical therapy including adequate volume resuscitation and treatment with 500 mg of oral vancomycin every 6 hours daily.
May be considered
Combination therapy with
parenteral metronidazole 500 mg every 8 hours.
CDI TREATMENT: PATIENT WITH ILEUS. May be beneficial: Addition of vancomycin enemas (500 mg every 6 hours). CDI TREATMENT SEVERE AND FULMINANT: May be considered: Fecal microbiota transplantation (FMT) may be considered in cases refractory to antibiotic therapy, especially when patients are poor surgical candidates.
TREAMENT: FIRST RECURRENCE OF CDI: Suggested: Tapering/pulsed dose vancomycin for patients experiencing first recurrence after an initial course of fidaxomicin, vancomycin, or metronidazole. Recommended: Fidaxomicin for patients experiencing a first recurrence after an initial course of vancomycin or metronidazole.
TREATMENT: FMT, PREVENTION OF RECURRENCE: Patients experiencing their second* or further recurrence of CDI (rCDI) should be treated with FMT to prevent other occurrences. FMT should be delivered through colonoscopy or capsules for treatment of rCDI. Delivery by enema is suggested if other methods are unavailable.
TREATMENT: rCDI WITHIN 8 WEEKS OF FIRST FMT: Suggested: Repeat FMT suggested for patients experiencing rCDI within 8 wks of initial FMT. May be used: Suppressive oral vancomycin may be used
to prevent further recurrence in patients with rCDI who are not FMT candidates, who relapsed after FMT, or require ongoing or frequent courses of antibiotics.
TREATMENT: HIGH RISK FOR RECURRENCE. Suggested: In patients with a history of CDI at high risk for recurrence, oral vancomycin is suggested during subsequent systemic antibiotic use to prevent additional recurrences. Bezlotoxumab* is suggested for prevention of rCDI in patients who are at high risk for recurrence.
CDI TREATMENT: BEZLOTUXUMAB. Recommended: Limit use of bezlotoxumab to those most likely to benefit, ie, aged ≥65 years with at least 1 of the following additional risk factors: experiencing their second episode of CDI within the past 6 months, immunocompromised, or severe CDI.
ANTISECRETORY TREATMENT: Recommended: Discontinuation of antisecretory therapy is recommended in patients with CDI, as long as there was appropriate indication for their use.
TREATMENT: SPECIAL POPULATIONS: IBD- Patients with IBD presenting with an acute flare and diarrhea should be tested for CDI. FMT should be considered for rCDI in patients with IBD. Childbearing- Vancomycin is recommended to treat pregnant, peripartum, and breastfeeding patients with CDI.
