Recommendations for the Treatment of Clostridioides difficile Infection in Adults
| Clinical Presentation . | Recommended and Alternative Treatments . | Comments . |
|---|---|---|
| Initial CDI episode | Preferred: Fidaxomicin 200 mg given twice daily for 10 days | Implementation depends upon available resources |
| Alternative: Vancomycin 125 mg given 4 times daily by mouth for 10 days | Vancomycin remains an acceptable alternative | |
| Alternative for nonsevere CDI, if above agents are unavailable: Metronidazole, 500 mg 3 times daily by mouth for 10–14 days | Definition of nonsevere CDI is supported by the following laboratory parameters: White blood cell count of 15 000 cells/µL or lower and a serum creatinine level <1.5 mg/dL | |
| First CDI recurrence | Preferred: Fidaxomicin 200 mg given twice daily for 10 days, OR twice daily for 5 days followed by once every other day for 20 days | … |
| Alternative: Vancomycin by mouth in a tapered and pulsed regimen | Tapered/pulsed vancomycin regimen example: 125 mg 4 times daily for 10–14 days, 2 times daily for 7 days, once daily for 7 days, and then every 2 to 3 days for 2 to 8 weeks | |
| Alternative: Vancomycin 125 mg given 4 times daily by mouth for 10 days | Consider a standard course of vancomycin if metronidazole was used for treatment of the first episode | |
| Adjunctive treatment: Bezlotoxumab 10 mg/kg given intravenously once during administration of SOC antibioticsa | Data when combined with fidaxomicin are limited. Caution for use in patients with congestive heart failureb | |
| Second or subsequent CDI recurrence | Fidaxomicin 200 mg given twice daily for 10 days, OR twice daily for 5 days followed by once every other day for 20 days | … |
| Vancomycin by mouth in a tapered and pulsed regimen | … | |
| Vancomycin 125 mg 4 times daily by mouth for 10 days followed by rifaximin 400 mg 3 times daily for 20 days | … | |
| Fecal microbiota transplantation | The opinion of the panel is that appropriate antibiotic treatments for at least 2 recurrences (ie, 3 CDI episodes) should be tried prior to offering fecal microbiota transplantation | |
| Adjunctive treatment: Bezlotoxumab 10 mg/kg given intravenously once during administration of SOC antibioticsa | Data when combined with fidaxomicin are limited. Caution for use in patients with congestive heart failurea | |
| Fulminant CDI | Vancomycin 500 mg 4 times daily by mouth or by nasogastric tube. If ileus, consider adding rectal instillation of vancomycin. Intravenously administered metronidazole (500 mg every 8 hours) should be administered together with oral or rectal vancomycin, particularly if ileus is present | Definition of fulminant CDI is supported by: Hypotension or shock, ileus, megacolon |
| Clinical Presentation . | Recommended and Alternative Treatments . | Comments . |
|---|---|---|
| Initial CDI episode | Preferred: Fidaxomicin 200 mg given twice daily for 10 days | Implementation depends upon available resources |
| Alternative: Vancomycin 125 mg given 4 times daily by mouth for 10 days | Vancomycin remains an acceptable alternative | |
| Alternative for nonsevere CDI, if above agents are unavailable: Metronidazole, 500 mg 3 times daily by mouth for 10–14 days | Definition of nonsevere CDI is supported by the following laboratory parameters: White blood cell count of 15 000 cells/µL or lower and a serum creatinine level <1.5 mg/dL | |
| First CDI recurrence | Preferred: Fidaxomicin 200 mg given twice daily for 10 days, OR twice daily for 5 days followed by once every other day for 20 days | … |
| Alternative: Vancomycin by mouth in a tapered and pulsed regimen | Tapered/pulsed vancomycin regimen example: 125 mg 4 times daily for 10–14 days, 2 times daily for 7 days, once daily for 7 days, and then every 2 to 3 days for 2 to 8 weeks | |
| Alternative: Vancomycin 125 mg given 4 times daily by mouth for 10 days | Consider a standard course of vancomycin if metronidazole was used for treatment of the first episode | |
| Adjunctive treatment: Bezlotoxumab 10 mg/kg given intravenously once during administration of SOC antibioticsa | Data when combined with fidaxomicin are limited. Caution for use in patients with congestive heart failureb | |
| Second or subsequent CDI recurrence | Fidaxomicin 200 mg given twice daily for 10 days, OR twice daily for 5 days followed by once every other day for 20 days | … |
| Vancomycin by mouth in a tapered and pulsed regimen | … | |
| Vancomycin 125 mg 4 times daily by mouth for 10 days followed by rifaximin 400 mg 3 times daily for 20 days | … | |
| Fecal microbiota transplantation | The opinion of the panel is that appropriate antibiotic treatments for at least 2 recurrences (ie, 3 CDI episodes) should be tried prior to offering fecal microbiota transplantation | |
| Adjunctive treatment: Bezlotoxumab 10 mg/kg given intravenously once during administration of SOC antibioticsa | Data when combined with fidaxomicin are limited. Caution for use in patients with congestive heart failurea | |
| Fulminant CDI | Vancomycin 500 mg 4 times daily by mouth or by nasogastric tube. If ileus, consider adding rectal instillation of vancomycin. Intravenously administered metronidazole (500 mg every 8 hours) should be administered together with oral or rectal vancomycin, particularly if ileus is present | Definition of fulminant CDI is supported by: Hypotension or shock, ileus, megacolon |
The recommendations are based the 2017 guidelines and these current focused guidelines. Abbreviations: CDI, Clostridioides difficile infection; SOC, standard of care.
aBezlotoxumab may also be considered for patients with other risks for CDI recurrence but implementation depends upon available resources and logistics for intravenous administration, particularly for those with an initial CDI episode. Additional risk factors for CDI recurrence include age >65 years, immunocompromised host (per history or use of immunosuppressive therapy), and severe CDI on presentation.
bThe Food and Drug Administration warns that “in patients with a history of congestive heart failure (CHF), bezlotoxumab should be reserved for use when the benefit outweighs the risk.”
Recommendations for the Treatment of Clostridioides difficile Infection in Adults
| Clinical Presentation . | Recommended and Alternative Treatments . | Comments . |
|---|---|---|
| Initial CDI episode | Preferred: Fidaxomicin 200 mg given twice daily for 10 days | Implementation depends upon available resources |
| Alternative: Vancomycin 125 mg given 4 times daily by mouth for 10 days | Vancomycin remains an acceptable alternative | |
| Alternative for nonsevere CDI, if above agents are unavailable: Metronidazole, 500 mg 3 times daily by mouth for 10–14 days | Definition of nonsevere CDI is supported by the following laboratory parameters: White blood cell count of 15 000 cells/µL or lower and a serum creatinine level <1.5 mg/dL | |
| First CDI recurrence | Preferred: Fidaxomicin 200 mg given twice daily for 10 days, OR twice daily for 5 days followed by once every other day for 20 days | … |
| Alternative: Vancomycin by mouth in a tapered and pulsed regimen | Tapered/pulsed vancomycin regimen example: 125 mg 4 times daily for 10–14 days, 2 times daily for 7 days, once daily for 7 days, and then every 2 to 3 days for 2 to 8 weeks | |
| Alternative: Vancomycin 125 mg given 4 times daily by mouth for 10 days | Consider a standard course of vancomycin if metronidazole was used for treatment of the first episode | |
| Adjunctive treatment: Bezlotoxumab 10 mg/kg given intravenously once during administration of SOC antibioticsa | Data when combined with fidaxomicin are limited. Caution for use in patients with congestive heart failureb | |
| Second or subsequent CDI recurrence | Fidaxomicin 200 mg given twice daily for 10 days, OR twice daily for 5 days followed by once every other day for 20 days | … |
| Vancomycin by mouth in a tapered and pulsed regimen | … | |
| Vancomycin 125 mg 4 times daily by mouth for 10 days followed by rifaximin 400 mg 3 times daily for 20 days | … | |
| Fecal microbiota transplantation | The opinion of the panel is that appropriate antibiotic treatments for at least 2 recurrences (ie, 3 CDI episodes) should be tried prior to offering fecal microbiota transplantation | |
| Adjunctive treatment: Bezlotoxumab 10 mg/kg given intravenously once during administration of SOC antibioticsa | Data when combined with fidaxomicin are limited. Caution for use in patients with congestive heart failurea | |
| Fulminant CDI | Vancomycin 500 mg 4 times daily by mouth or by nasogastric tube. If ileus, consider adding rectal instillation of vancomycin. Intravenously administered metronidazole (500 mg every 8 hours) should be administered together with oral or rectal vancomycin, particularly if ileus is present | Definition of fulminant CDI is supported by: Hypotension or shock, ileus, megacolon |
| Clinical Presentation . | Recommended and Alternative Treatments . | Comments . |
|---|---|---|
| Initial CDI episode | Preferred: Fidaxomicin 200 mg given twice daily for 10 days | Implementation depends upon available resources |
| Alternative: Vancomycin 125 mg given 4 times daily by mouth for 10 days | Vancomycin remains an acceptable alternative | |
| Alternative for nonsevere CDI, if above agents are unavailable: Metronidazole, 500 mg 3 times daily by mouth for 10–14 days | Definition of nonsevere CDI is supported by the following laboratory parameters: White blood cell count of 15 000 cells/µL or lower and a serum creatinine level <1.5 mg/dL | |
| First CDI recurrence | Preferred: Fidaxomicin 200 mg given twice daily for 10 days, OR twice daily for 5 days followed by once every other day for 20 days | … |
| Alternative: Vancomycin by mouth in a tapered and pulsed regimen | Tapered/pulsed vancomycin regimen example: 125 mg 4 times daily for 10–14 days, 2 times daily for 7 days, once daily for 7 days, and then every 2 to 3 days for 2 to 8 weeks | |
| Alternative: Vancomycin 125 mg given 4 times daily by mouth for 10 days | Consider a standard course of vancomycin if metronidazole was used for treatment of the first episode | |
| Adjunctive treatment: Bezlotoxumab 10 mg/kg given intravenously once during administration of SOC antibioticsa | Data when combined with fidaxomicin are limited. Caution for use in patients with congestive heart failureb | |
| Second or subsequent CDI recurrence | Fidaxomicin 200 mg given twice daily for 10 days, OR twice daily for 5 days followed by once every other day for 20 days | … |
| Vancomycin by mouth in a tapered and pulsed regimen | … | |
| Vancomycin 125 mg 4 times daily by mouth for 10 days followed by rifaximin 400 mg 3 times daily for 20 days | … | |
| Fecal microbiota transplantation | The opinion of the panel is that appropriate antibiotic treatments for at least 2 recurrences (ie, 3 CDI episodes) should be tried prior to offering fecal microbiota transplantation | |
| Adjunctive treatment: Bezlotoxumab 10 mg/kg given intravenously once during administration of SOC antibioticsa | Data when combined with fidaxomicin are limited. Caution for use in patients with congestive heart failurea | |
| Fulminant CDI | Vancomycin 500 mg 4 times daily by mouth or by nasogastric tube. If ileus, consider adding rectal instillation of vancomycin. Intravenously administered metronidazole (500 mg every 8 hours) should be administered together with oral or rectal vancomycin, particularly if ileus is present | Definition of fulminant CDI is supported by: Hypotension or shock, ileus, megacolon |
The recommendations are based the 2017 guidelines and these current focused guidelines. Abbreviations: CDI, Clostridioides difficile infection; SOC, standard of care.
aBezlotoxumab may also be considered for patients with other risks for CDI recurrence but implementation depends upon available resources and logistics for intravenous administration, particularly for those with an initial CDI episode. Additional risk factors for CDI recurrence include age >65 years, immunocompromised host (per history or use of immunosuppressive therapy), and severe CDI on presentation.
bThe Food and Drug Administration warns that “in patients with a history of congestive heart failure (CHF), bezlotoxumab should be reserved for use when the benefit outweighs the risk.”
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