VASF Clostridioides Difficile Infection (CDI) Treatment Guidelines

Site: 
VA Medical Center San Francisco
Modified Date: 
September 27, 2023
Category: 
Syndrome Specific Guidelines
 

Clostridioides difficile Infection (CDI)

Clinical Definition Supportive Clinical Data
Asymptomatic colonization Positive C. difficile PCR (only) WITHOUT diarrhea, ileus, or colitis
Active infection Positive C. difficile PCR AND positive toxin A/B AND diarrhea ( > 3 unformed stools / 24 hours), ileus, or presence of pseudomembranous colitis on colonoscopic or histopathologic exam
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

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):

  • Age > 65 years old, immunosuppression, history of inflammatory bowel disease
  • Concomitant antibiotic use during CDI treatment
1st Recurrence Fidaxomicin 200 mg PO q12h for 10 days

 

 

≥ 2nd Recurrence

Vancomycin oral solution in a tapered regimen:

  • Vancomycin PO 125mg PO q6h x14 days, then 125mg PO q12h x7 days, then 125mg PO daily x7 days, then 125mg PO every other day x7 days, then 125mg every 3rd day x14 days

PLUS

Evaluate for fecal microbiota transplant (FMT), consider ID or GI consult

 

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 above).
  • ID or GI and surgical consultation should be obtained for severely ill patients.

 

C. difficile Prophylaxis Agents

Bezlotoxumab

10 mg/kg IV single, life-time dose

 

Infectious Diseases Section approval is required

 

Place pharmacy non-formulary drug consult (PADR/ NFDR)

Initial episode: Toxin antigen protein positive AND meets one of the following:

  • Hematologic cancer with neutropenia (ANC < 500) expected > 30 days
  • Recent bone-marrow transplant or treatment for GVHD
  • Solid-organ transplant < 3 months
  • Patient does not have history of heart failure

 

1st recurrence: If recurrence occurred within previous 6 months

≥ 2nd recurrence: All patients

  • Must be administered during CDI treatment course
  • May be administered as in outpatient in the infusion center
  • Patients with underlying congestive heart failure are at higher risk of mortality due to cardiac failure, reserved for use when the benefit outweighs the risk

Vancomycin

125 mg PO q12h

Must meet ALL of the following criteria:

  • Recurrent episode of CDI within the past 6 months
  • Patient requires treatment with antibiotics (beta-lactams, quinolones, or clindamycin) not directed against CDI in the inpatient setting
  • No history of vancomycin allergy

Initiate as soon as possible and continue until antibiotics not directed against CDI are discontinued

VOWST™ (FMT)

 

ID or GI section approval is required

 

Place pharmacy non-formulary drug consult (PADR)

Patients are ineligible if ONE of the following criteria are met:

  • Asymptomatic C. difficile colonization
  • ANC < 500 cells/m3
  • Is likely to require systemic antibiotics or pre-op antibiotics within 8 weeks after treatment
  • Inability to use magnesium citrate or polyethylene glycol or take VOWSTTM prior to first meal of day

Must meet ALL of the following criteria:

  • At least 2nd recurrent CDI (3rd CDI episode overall) within previous 12 months
  • At least one CDI episode was treated with fidaxomicin, unless not tolerated or contraindicated
  • Previously received bezlotoxumab, unless not tolerated or contraindicated
  • Is able to start VOWSTTM within 2 to 4 days after completing of current CDI treatment

Pretreatment:

  • Take 296 mL magnesium citrate 8 hours prior to first dose of VOWSTTM
    • If renal impairment, prescribe 250 mL polyethylene glycol

Treatment:

  • Avoid eating or drinking, except for small amounts of water, for at least 8 hours prior to first dose
  • Take 4 capsules of VOWSTTM PO on an empty stomach prior to 1st meal of day once daily x 3 days
Clinical Pearls
  • If an inciting antimicrobial is suspected (most commonly clindamycin, aminopenicillins, third generation cephalosporins, and fluoroquinolones), 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.
  • If patient is an FMT candidate, contact ID or GI for VOWSTTM