Clostridioides difficile Infection: Update on Management

 

Am Fam Physician. 2020 Feb 1;101(3):168-175.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/clostridium-difficile-c-diff-infection.

Author disclosure: No relevant financial affiliations.

Guidelines for the diagnosis and treatment of Clostridioides difficile infection have recently been updated. Risk factors include recent exposure to health care facilities or antibiotics, especially clindamycin. C. difficile infection is characterized by a wide range of symptoms, from mild or moderate diarrhea to severe disease with pseudomembranous colitis, colonic ileus, toxic megacolon, sepsis, or death. C. difficile infection should be considered in patients who are not taking laxatives and have three or more episodes of unexplained, unformed stools in 24 hours. Testing in these patients should start with enzyme immunoassays for glutamate dehydrogenase and toxins A and B or nucleic acid amplification testing. In children older than 12 months, testing is recommended only for those with prolonged diarrhea and risk factors. Treatment depends on whether the episode is an initial vs. recurrent infection and on the severity of the infection based on white blood cell count, serum creatinine level, and other clinical signs and symptoms. For an initial episode of nonsevere C. difficile infection, oral vancomycin or oral fidaxomicin is recommended. Metronidazole is no longer recommended as first-line therapy for adults. Fecal microbiota transplantation is a reasonable treatment option with high cure rates in patients who have had multiple recurrent episodes and have received appropriate antibiotic therapy for at least three of the episodes. Good antibiotic stewardship is a key strategy to decrease rates of C. difficile infection. In routine or endemic settings, hands should be cleaned with either soap and water or an alcohol-based product, but during outbreaks soap and water is superior. The Infectious Diseases Society of America does not recommend the use of probiotics for prevention of C. difficile infection.

Clostridioides difficile (formerly Clostridium difficile) is an anaerobic, spore-forming, gram-positive bacillus identified in 1978 as the primary cause of antibiotic-associated diarrhea and pseudomembranous colitis.1 The rate of C. difficile infections increased from 13 to 14.2 cases per 1,000 adults between 2011 and 2015; it is now the most commonly reported nosocomial pathogen in the United States.2 Health care costs associated with C. difficile infection were estimated at $4.8 billion for acute care facilities in 2008.3 This article discusses recently updated guidelines for the diagnosis and treatment of C. difficile infection.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

A two-step algorithm should be used to guide diagnostic testing for Clostridioides difficile infection: enzyme immunoassay for glutamate dehydrogenase and toxins A and B, followed by nucleic acid amplification testing if initial results are indeterminate. For patients likely to have C. difficile infection based on clinical symptoms, either nucleic acid amplification testing or the two-step algorithm is appropriate.6

C

Guideline recommendation based on low-quality, small diagnostic studies

Oral vancomycin and fidaxomicin (Dificid) are preferred over metronidazole for initial episodes of C. difficile infection.6,25

C

Recommendation from an evidence-based practice guideline and large disease-oriented study

Fecal microbiota transplantation is recommended for patients with multiple recurrences of C. difficile infection in whom appropriate antibiotic therapy has been ineffective.6,27,28

B

Based on practice guidelines and consistent findings from small randomized controlled trials evaluating diarrhea

Antibiotic stewardship reduces rates of C. difficile infection.6

C

Guideline recommendation based on low- to moderate-quality longitudinal cohort studies


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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ANNE MOUNSEY, MD, is a professor of clinical medicine in the Department of Family Medicine at the University of North Carolina, Chapel Hill....

KELLY LACY SMITH, MD, is an assistant professor of clinical medicine in the Department of Family Medicine at the University of North Carolina.

VINAY C. REDDY, MD, MPH, is an assistant professor of clinical medicine in the Department of Family Medicine at the University of North Carolina.

SARAH NICKOLICH, MD, is an assistant professor of clinical medicine in the Department of Family and Community Medicine at the Penn State Health Milton S. Hershey Medical Center, Hershey, Pa.

Address correspondence to Anne Mounsey, MD, University of North Carolina School of Medicine, 590 Manning Dr., Chapel Hill, NC 27514 (email: anne_mounsey@med.unc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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