The main highlights of the updated guidelines are the following:
Recommendations on diagnostic testing for Clostridiodes difficile:
- 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.
- 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.
- 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.
- 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.
- 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 neonates and infants
- 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
- The usual first step is to eliminate the use of any antibiotic suspected of triggering the CDI.
- For treatment of the initial episode of CDI, the recommendation is for fidaxomicin over metronidazole with the use of vancomycin as an acceptable alternative.
- For recurrent CDI, fidaxomicin is recommended over vancomycin. As an alternative treatment for patients with multiple recurrences, vancomycin can be used in a tapered and pulsed regimen followed by fecal transplantation (FMT) as an option.
- For patients with a recurrent CDI episode within the last 6 months, the suggested recommendation is for use of bezlotoxumab in combination with fidaxomicin. Bezlotoxumab is a monoclonal antibody that targets toxin B produced by C. difficile. (There is a warning that in patients with a history of congestive heart failure (CHF), bezlotoxumab should be reserved for use when the benefit outweighs the risk).
- Note: FMT is recommended only for patients with multiple recurrences of CDI who have failed appropriate antibiotic treatments and where appropriate screening of donor and donor fecal specimens has been performed
Treatment for fulminant CDI is oral vancomycin. If serious complications are present in the patient, then the recommendation is to use intravenous metronidazole together with oral or rectal vancomycin administration.
- If severely ill patients with CDI require surgical management, the recommendation is colectomy with preservation of the rectum.
Note: The updated guidelines also have suggestions for preventing the spread of C. difficile, similar to the 2010 guidelines. However, no recommendation is made for the use of probiotics in CDI patients.
