The main highlights of the updated guidelines are the following:
Recommendations on diagnostic testing for Clostridium difficile:
(1). Patients with unexplained and new-onset of unformed watery stools occurring 3 or more times within 24 hours are the preferred target population for testing for CDI.
(2). The recommended testing methods for detecting patients at increased risk for clinically significant CDI is a combination of stool toxin detection and GDH antigen and NAAT testing as part of a multistep algorithm approach. The multistep algorithm can be used in one or more of the following testing combinations:
- GDH antigen and toxin A and/or B testing combination or
- GDH plus toxin arbitrated by NAAT testing or
- NAAT plus toxin rather than using NAAT testing alone.
(3). Repeat testing within 7 days during the same diarrhea episode is not recommended. Testing stool from asymptomatic patients is not recommended except for epidemiological studies.
(4). Testing for other fecal biological markers (such as lactoferrin) is not recommended because there are insufficient data to support the use of biological markers as an adjunct to diagnosis.
(5). Testing for CDI in neonates or infants (<12 months of age) with diarrhea should not be routinely performed because of the high prevalence of the C difficile bacteria in neonate and infants
(6). Testing for CDI should not be routinely performed in children with diarrhea who are 1-2 years of age unless other infectious or noninfectious causes have been excluded. In children greater or equal to 2 years of age, testing for CDI is recommended if the children have prolonged or worsening diarrhea and other risk factors.
Recommendations on Treatments of CDI
(1), Either vancomycin or fidaxomicin is recommended over metronidazole for the treatment of the initial episode of CDI.
(2). If access to vancomycin or fidaxomicin is limited, metronidazole is recommended for the initial episode of non-severe CDI only. Clinical studies indicate that the cure rates are higher for vancomycin and fidaxomicin than for metronidazole.
(3). Treatment for fulminant CDI is oral vancomycin. If serious complications are present in the patient, then recommendation is for use of intravenously metronidazole together with oral or rectal vancomycin administration.
(4). If severely ill patients with CDI require surgical management, recommendation is colectomy with preservation of the rectum.
(5). Recurrent CDI treatment recommendations depend on the frequency of recurrence. The first recurrence of CDI should be treated with oral vancomycin as a tapered approach or a 10 day course of fidaxomicin treatment. Several antibiotic options are recommended for patients with more than one occurrence of CDI and include a combination of antibiotics.
(6). Fecal microbiota transplantation (FMT) is recommended for patients with multiple recurrences of CDI (2 or more occurrences) who have failed to respond to appropriate antibiotic treatments.
Note: The updated guidelines also have suggestions for the prevention of the spread of C diff similar to the 2010 guidelines. However, no recommendation is made for the use of probiotics in CDI patients.