_______________________________________________________________ Healthcare-Associated Infections
SHEA/IDSA GUIDELINES FOR THE TREATMENT OF CLOSTRIDIOIDES DIFFICILE INFECTION ACCORDING TO SEVERITY OF DISEASE
Severity of Disease
Preferred Treatment
Mild to severe (WBC ≤15,000)
Fidaxomicin 200 mg twice daily for 10 days (Conditional/Moderate) Alternative: Vancomycin 125 mg orally four times daily for 10 days
Severe (WBC >15,000, serum creatinine >1.5 mg/dL) Fulminant (hypotension, ileus, or megacolon)
Vancomycin PO 125 mg, four times per day for 10 days OR fidaxomicin 200 mg twice daily for 10 days (Strong/High) Vancomycin 500 mg, four times per day by mouth or nasogastric tube If ileus, add rectal administration of vancomycin and intravenous metronidazole 500 mg every 8 hours a (Strong/Moderate) Vancomycin PO 125 mg four times daily for 10 days; fidaxomicin 200 mg twice daily for 10 days if vancomycin was used initially Vancomycin in a prolonged tapered and pulsed regimen OR vancomycin standard 10-day regimen followed by rifaximin 400 mg three times daily for 20 days Fecal microbiota transplantation (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. Three separate safety alerts have been published by the FDA since June 2019, which outline adverse events or potential adverse events among recipients of FMT.
Recurrent
First recurrence
Second recurrence or more
Bezlotoxumab as a co-intervention (conditional recommendation, very low certainty evidence), given as a one-time infusion at a dose of 10 mg/kg over 60 minutes. a If ileus is present, vancomycin may be given per rectum as a retention enema, at a dose of 500 mg/100 mL normal saline, every 6 hours. Source: [274; 283; 284] Table 17
by the FDA in 2016 and was the first humanized monoclonal antibody effective against C. difficile toxin B. It is approved for the prevention of recurrent C. difficile infection in high-risk adults [274; 286]. Bezlotoxumab is administered as a one-time infusion at a recommended dose of 10 mg/kg over 60 minutes [274; 286]. In patients with a history of congestive heart failure, the FDA warns that bezlotoxumab should be reserved for use when the benefit outweighs the risk [274; 286]. Surgical management may be necessary for severe, fulminant cases of C. difficile colitis. In such cases, subtotal colectomy with preservation of the rectum is advisable; alternatively, a diverting loop ileostomy with colonic lavage followed by ante- grade vancomycin flushes may lead to improved outcomes [35]. In addition to infection-directed antibiotics, treatment of C. dif- ficile infection also includes fluid replacement, and electrolyte normalization [287]. The use of antiperistaltic agents should be avoided, as they may obscure symptoms, lead to retained toxin, and precipitate toxic megacolon (level III, C) [35]. The use of probiotics has been suggested as an adjunct to antibiotic treatment, but a systematic review found insufficient data to support probiotics as adjunct therapy and no evidence to sup- port its use alone [288].
According to the IDSA and the SHEA, fidaxomicin is recommended over
vancomycin for an initial episode of C. difficile infection. Vancomycin remains an acceptable alternative. (https://www.idsociety.org/practice- guideline/clostridioides-difficile-2021-focused-update. Last accessed January 26, 2025.) Level of Evidence : Consensus Statement/Expert Opinion For patients with a recurrent episode of C. difficile (within the last six months), the SHEA/IDSA panel conditionally recommends using bezlotoxumab as a co-intervention with standard-of-care antibiotics, rather than antibiotics alone [274]. Bezlotoxumab has been shown to be effective in preventing C. difficile infection when administered at any time before ending antibacterial treatment [285]. Patients with a primary episode and other risk factors for recurrence (e.g., 65 years of age and older, immunocompromised, severe C. difficile , C. difficile infection in the last six months) may benefit from receiving bezlotoxumab [274]. Bezlotoxumab was approved
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