Clostridioides Difficile Infection (CDI)
Diagnosis
- Presence of diarrhea defined as 3+ unformed stools within 24 hours AND either a positive stool test for C. difficle or presence of pseudomembranous colitis on colonoscopic or histopathologic exam
Clinical Definition | Supportive Clinical Data |
Asymptomatic colonization | Positive C. difficle PCR (only) WITHOUT diarrhea, ileus, or colitis |
Active infection | Positive C. difficle PCR AND positive toxin A/B or GDH antigen AND diarrhea, ileus, or colitis |
Recurrent infection | Active infection that occurs within 8 weeks after completing treatment of prior CDI episode |
Fulminant | Active infection PLUS hypotension, shock, ileus, megacolon, or perforation |
C. Difficile Treatment Regimens
Initial episode Mild /Moderate/ Severe |
Vancomycin 125 mg PO q6h for 10 days OR Fidaxomicin 200 mg PO q12h for 10 days for patients at increased risk of CDI recurrence (at least 1):
|
1st Recurrence | Fidaxomicin 200 mg PO q12h for 10 days |
≥ 2nd Recurrence |
Vancomycin oral solution in a tapered regimen:
PLUS Evaluate for fecal microbiota transplant (FMT) |
Fulminant |
Vancomycin 500mg PO q6h If ileus is present, add metronidazole 500mg IV q8h and consider Vancomycin 500mg in 100ml normal saline given as a retention enema q6h. Therapy should be followed by a vancomycin taper (see below). ID or GI and surgical consultation should be obtained for severely ill patients. |
C. Difficile Prophylaxis Agents
Bezlotoxumab 10 mg/kg IV single dose
Infectious Diseases Section approval is required |
Initial episode: Toxin antigen protein positive AND meets one of the following:
1st recurrence: If recurrence occurred within previous 6 months ≥ 2nd recurrence: All patients
|
Vancomycin 125 mg PO q12h |
Must meet ALL of the following criteria:
Initiate as soon as possible and continue until antibiotics not directed against CDI are discontinued |
Clinical Pearls
- If an inciting antimicrobial is suspected discontinue the agent as soon as possible.
- The use of antimotility agents (loperamide, etc.) should be avoided.
- If severe or fulminant disease is suspected, initiate empiric treatment while awaiting assay results. If the assay is negative, use clinical judgment when deciding if therapy should be discontinued.
- Use caution with high dose oral/rectal vancomycin (500mg Q6H) in patients with renal insufficiency, as significant absorption can occur in the setting of colitis and systemic accumulation could lead to ototoxicity, nephrotoxicity, or other adverse effects.
- Always wash hands with soap and water after examining a patient with suspected/confirmed C. difficile, as alcohol-based sanitizers do NOT kill spores.
- FMT is no longer available from ID Clinic. Consider contacting GI for guidance