Materiały źródłowe

• #1 Clostridioides (Clostridium) Difficile Colitis: Background, Etiology, Pathophysiology

  https://emedicine.medscape.com/article/186458-overview

  Once infected with C difficile, the rate of disease recurrence is 20-40% when using metronidazole and vancomycin antibiotics as first-line therapy. […] Fidaxomicin is now recommended as first-line treatment due to a lower risk of CDI recurrence. […] In patients with CDI who develop fulminant colitis, early surgical consultation is crucial. […] The use of oral metronidazole or vancomycin produces response rates of greater than 95% in mild to moderate cases, with symptomatic improvement (diarrhea) in as little as 3-4 days and complete resolution in 7-10 days. […] However, approximately 20-27% of patients treated for a first episode of C difficile colitis relapse after successfully completing therapy, typically 3 days to 3 weeks after treatment has ended. […] Patients who relapse once are at an even greater risk for further relapses; the relapse rate for patients with 2 or more relapses is 65%.

• #2 Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by SHEA/IDSA

  https://www.idsociety.org/practice-guideline/clostridium-difficile/

  Discontinue therapy with the inciting antibiotic agent(s) as soon as possible, as this may influence the risk of CDI recurrence (strong recommendation, moderate quality of evidence). […] Antibiotic therapy for CDI should be started empirically for situations where a substantial delay in laboratory confirmation is expected, or for fulminant CDI (described in section XXX) (weak recommendation, low quality of evidence). […] Either vancomycin or fidaxomicin is recommended over metronidazole for an initial episode of CDI. The dosage is vancomycin 125 mg orally 4 times per day or fidaxomicin 200 mg twice daily for 10 days (strong recommendation, high quality of evidence). […] In settings where access to vancomycin or fidaxomicin is limited, we suggest using metronidazole for an initial episode of nonsevere CDI only (weak recommendation, high quality of evidence). The suggested dosage is metronidazole 500 mg orally 3 times per day for 10 days. Avoid repeated or prolonged courses due to risk of cumulative and potentially irreversible neurotoxicity (strong recommendation, moderate quality of evidence).

• #3 CDI Treatment Clostridioides (Clostridium) difficile Toolkit for Long-term Care Facilities – MN Dept. of Health

  https://www.health.state.mn.us/diseases/cdiff/hcp/ltctoolkit/treatment.html

  Whenever possible, other antibiotics should be discontinued. In a small number of patients, diarrhea may go away when other antibiotics are stopped. Proton pump inhibitors (PPI) and antiperistaltic agents should also be avoided for all residents suspected of having or diagnosed with CDI. […] Treatment of primary infection caused by C. difficile is an antibiotic such as metronidazole, vancomycin, or fidaxomicin. While metronidazole is not approved for treating C. difficile infections by the FDA, it has been commonly recommended and used for mild C. difficile infections; however, it should not be used for severe C. difficile infections. Whenever possible, treatment should be given by mouth and continued for a minimum of 10 days. […] One problem with antibiotics used to treat primary C. difficile infection is that the infection returns in about 20 percent of patients. In a small number of these patients, the infection returns over and over and can be quite debilitating. While a first return of a C. difficile infection is usually treated with the same antibiotic used for primary infection, all future infections should be managed with oral vancomycin or fidaxomicin.

• #4 Clostridioides difficile infection

  https://www.hse.ie/eng/services/list/2/gp/antibiotic-prescribing/conditions-and-treatments/gastro/clostridium-difficile/

  General measures advised in the treatment of patients with CDI: Patients/ residents of a healthcare facility with potentially infectious diarrhoea (i.e. no clear alternative cause) should be isolated with Standard and Contact Precautions as soon as possible. […] Stop unnecessary antimicrobial therapy (if possible). […] Ensure adequate nutrition and replacement of fluid and electrolytes. […] Avoid anti-motility medications. […] Review proton pump inhibitor use. […] If an antibiotic is still essential, consider changing to one with a lower risk of causing CDI. […] It is recommended to discontinue antibiotic therapy with the inciting antibiotic if possible and closely monitor the patient for 48 hours. C. difficile treatment should be initiated if any signs of clinical deterioration are observed.

• #5 Clostridioides (Clostridium) Difficile Colitis Treatment & Management: Approach Considerations, Pharmacologic Management, Fecal Microbiota Transplantation

  https://emedicine.medscape.com/article/186458-treatment

  The decision to treat C difficile infection (CDI) and the type of therapy administered depend on the severity of infection, as well as the local epidemiology and type of C difficile strains present. Except for perioperative prophylaxis, it is recommended that the use of cephalosporin and clindamycin be restricted for infection prevention. No treatment is necessary for asymptomatic carriers. […] For symptomatic patients, the Infectious Diseases Society of America (ISDA) and Society for Healthcare Epidemiology of America (SHEA) 2021 updated guideline for CDI treatment recommend administering fidaxomicin for initial and recurrent infections, with oral vancomycin as an alternative. Fecal microbiota transplantation (FMT) may also be added after treating the second recurrence. Bezlotoxumab had been recommended as adjunctive treatment for recurrent CDI, but it has been discontinued as of January 31, 2025.

• #6 Biliary Tract Disorders, Gallbladder Disorders, & Gallstone Pancreatitis | ACG

  https://gi.org/topics/c-difficile-infection/

  First, it would be ideal to stop the antibiotic that led to the infection in the first place. This may not always be possible, however, as some infections, like severe bone or heart infections, need long-term antibiotics. Treatment for C. difficile is based on the severity of the infection. The current guidelines separate C. difficile infection into 3 categories: non-severe, severe and fulminant. Non-severe infections are usually treated in the outpatient setting. The standard of care treatment is vancomycin 125mg, four times a day for ten days or fidaxomicin 200mg, twice a day for ten days. The vast majority of patients will have resolution of symptoms after appropriate treatment. If diarrhea does not improve with appropriate antibiotics, an alternative diagnosis for diarrhea should be considered. Antidiarrheal drugs are not recommended to treat C. difficile infection and should only be used in consultation with your physician.

• #7 Clostridioides (Clostridium) Difficile Colitis Treatment & Management: Approach Considerations, Pharmacologic Management, Fecal Microbiota Transplantation

  https://emedicine.medscape.com/article/186458-treatment

  In patients with severe, complicated, or fulminant CDI (hypotension, shock, ileus or megacolon), oral (or via nasogastric tube) vancomycin 500 mg every 6 hours along with intravenous (IV) metronidazole is recommended. Rectal vancomycin may also be added in patients with ileus. […] Treatment recommendations for CDI have evolved over the past few years. One reason for change is the frequent relapse rate of CDI (20-27%). In 2021, the ISDA recommended using fidaxomicin first line for treatment of an initial CDI episode as well as subsequent recurrence. Relative to vancomycin, fidaxomicin is not only a more targeted intestinal antibiotic but also associated with fewer CDI recurrences. Vancomycin is still considered to be an acceptable alternative. However, metronidazole is no longer recommended unless fidaxomicin and vancomycin are not available.

• #8 Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by SHEA/IDSA

  https://www.idsociety.org/practice-guideline/clostridium-difficile/

  Discontinue therapy with the inciting antibiotic agent(s) as soon as possible, as this may influence the risk of CDI recurrence (strong recommendation, moderate quality of evidence). […] Antibiotic therapy for CDI should be started empirically for situations where a substantial delay in laboratory confirmation is expected, or for fulminant CDI (described in section XXX) (weak recommendation, low quality of evidence). […] Either vancomycin or fidaxomicin is recommended over metronidazole for an initial episode of CDI. The dosage is vancomycin 125 mg orally 4 times per day or fidaxomicin 200 mg twice daily for 10 days (strong recommendation, high quality of evidence). […] In settings where access to vancomycin or fidaxomicin is limited, we suggest using metronidazole for an initial episode of nonsevere CDI only (weak recommendation, high quality of evidence). The suggested dosage is metronidazole 500 mg orally 3 times per day for 10 days. Avoid repeated or prolonged courses due to risk of cumulative and potentially irreversible neurotoxicity (strong recommendation, moderate quality of evidence).

• #9 Clostridioides (Clostridium) Difficile Colitis Treatment & Management: Approach Considerations, Pharmacologic Management, Fecal Microbiota Transplantation

  https://emedicine.medscape.com/article/186458-treatment

  Initial treatment: Treatment with fidaxomicin 200 mg by mouth twice a day for 10 days. If fidaxomicin is not available, then use oral vancomycin 125 mg by mouth four times a day for 10 days as an alternative. In nonsevere CDI (white blood cell [WBC] count 15,000 cells/uL and creatinine level 1.5 mg/dL), if fidaxomicin and vancomycin are not available, then use metronidazole 500 mg every 8 hours for 10-14 days. […] Fulminant (hypotension or shock, ileus, or megacolon) CDI: Vancomycin 500 mg every 6 hours by mouth or nasogastric tube, combined with IV metronidazole 500 mg every 8 hours. In patients with ileus, consider adding rectal vancomycin 500 mg every 6 hours in 100 mL normal saline as a retention enema. […] In a multicenter retrospective (2013-2014) study of CDI in 72 Spanish patients, fidaxomicin treatment was effective and well tolerated in patients with severe CDI as well as those at high risk of recurrent disease. The clinical cure rate was 90.3%, with a 16.7% recurrence and a 72.2% sustained cure.

• #10 Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by SHEA/IDSA

  https://www.idsociety.org/practice-guideline/clostridium-difficile/

  Discontinue therapy with the inciting antibiotic agent(s) as soon as possible, as this may influence the risk of CDI recurrence (strong recommendation, moderate quality of evidence). […] Antibiotic therapy for CDI should be started empirically for situations where a substantial delay in laboratory confirmation is expected, or for fulminant CDI (described in section XXX) (weak recommendation, low quality of evidence). […] Either vancomycin or fidaxomicin is recommended over metronidazole for an initial episode of CDI. The dosage is vancomycin 125 mg orally 4 times per day or fidaxomicin 200 mg twice daily for 10 days (strong recommendation, high quality of evidence). […] In settings where access to vancomycin or fidaxomicin is limited, we suggest using metronidazole for an initial episode of nonsevere CDI only (weak recommendation, high quality of evidence). The suggested dosage is metronidazole 500 mg orally 3 times per day for 10 days. Avoid repeated or prolonged courses due to risk of cumulative and potentially irreversible neurotoxicity (strong recommendation, moderate quality of evidence).

• #11 Clostridioides (Clostridium) Difficile Colitis Treatment & Management: Approach Considerations, Pharmacologic Management, Fecal Microbiota Transplantation

  https://emedicine.medscape.com/article/186458-treatment

  In patients with severe, complicated, or fulminant CDI (hypotension, shock, ileus or megacolon), oral (or via nasogastric tube) vancomycin 500 mg every 6 hours along with intravenous (IV) metronidazole is recommended. Rectal vancomycin may also be added in patients with ileus. […] Treatment recommendations for CDI have evolved over the past few years. One reason for change is the frequent relapse rate of CDI (20-27%). In 2021, the ISDA recommended using fidaxomicin first line for treatment of an initial CDI episode as well as subsequent recurrence. Relative to vancomycin, fidaxomicin is not only a more targeted intestinal antibiotic but also associated with fewer CDI recurrences. Vancomycin is still considered to be an acceptable alternative. However, metronidazole is no longer recommended unless fidaxomicin and vancomycin are not available.

• #12 Updated Clinical Practice Guidelines for C difficile Infection in Adults

  https://www.uspharmacist.com/article/updated-clinical-practice-guidelines-for-c-difficile-infection-in-adults

  The IDSA-SHEA guidelines suggest fidaxomicin as the preferred agent for treating initial CDI, with oral vancomycin considered an acceptable alternative. […] The IDSA-SHEA guidelines state that fidaxomicin for 10 days at a standard dosing regimen is the preferred treatment for an initial episode of CDI; this recommendation is conditional, with a moderate certainty of evidence. Oral vancomycin for 10 days at a standard dosing regimen is an acceptable alternative. […] The IDSA-SHEA guidelines suggest using fidaxomicin as a standard or extended-pulsed dosing regimen over vancomycin in patients with a first recurrence of CDI; this is a conditional recommendation with a low certainty of evidence. The guidelines also state that vancomycin (either standard dosing or a tapered and pulsed regimen) is an acceptable alternative.

• #13 Which C diff Treatment Is the Most Cost-Effective?

  https://www.contagionlive.com/view/which-c-diff-treatment-is-the-most-cost-effective-

  Though the drug is initially more expensive, treating C diff infection with fidaxomicin reduced costs overall by reducing CDI recurrences. […] One study, published on MDPI, compared the real-world cost-effectiveness and budget impact of fidaxomicin, vancomycin, and metronidazole for C difficile infection (CDI). […] Because fidaxomicin is a macrocyclic antibacterial drug that only targets C diff bacteria, it may significantly reduce the likelihood of CDI recurrence. […] Thus, a targeted agent like fidaxomicin would be an ideal choice for CDI patients, if the investigators could prove that the higher initial cost of the drug compensated by reducing subsequent expensive recurrences. […] The investigators found CDI recurrence was 6.5% for fidaxomicin recipients and 19.8% for patients who received vancomycin or metronidazole. Thus, an estimated 12 CDI recurrences were prevented by treatment with fidaxomicin.

• #14 Clostridioides (Clostridium) Difficile Colitis Treatment & Management: Approach Considerations, Pharmacologic Management, Fecal Microbiota Transplantation

  https://emedicine.medscape.com/article/186458-treatment

  In patients with severe, complicated, or fulminant CDI (hypotension, shock, ileus or megacolon), oral (or via nasogastric tube) vancomycin 500 mg every 6 hours along with intravenous (IV) metronidazole is recommended. Rectal vancomycin may also be added in patients with ileus. […] Treatment recommendations for CDI have evolved over the past few years. One reason for change is the frequent relapse rate of CDI (20-27%). In 2021, the ISDA recommended using fidaxomicin first line for treatment of an initial CDI episode as well as subsequent recurrence. Relative to vancomycin, fidaxomicin is not only a more targeted intestinal antibiotic but also associated with fewer CDI recurrences. Vancomycin is still considered to be an acceptable alternative. However, metronidazole is no longer recommended unless fidaxomicin and vancomycin are not available.

• #15 C. diff: Facts for Clinicians | C. diff | CDC

  https://www.cdc.gov/c-diff/hcp/clinical-overview/index.html

  If CDI is confirmed: […] Use antibiotics appropriately. […] CDI should usually be treated with an appropriate course (about 10 days) of treatment, including oral vancomycin or fidaxomicin.

• #16 Clostridioides (Clostridium) Difficile Colitis Treatment & Management: Approach Considerations, Pharmacologic Management, Fecal Microbiota Transplantation

  https://emedicine.medscape.com/article/186458-treatment

  Initial treatment: Treatment with fidaxomicin 200 mg by mouth twice a day for 10 days. If fidaxomicin is not available, then use oral vancomycin 125 mg by mouth four times a day for 10 days as an alternative. In nonsevere CDI (white blood cell [WBC] count 15,000 cells/uL and creatinine level 1.5 mg/dL), if fidaxomicin and vancomycin are not available, then use metronidazole 500 mg every 8 hours for 10-14 days. […] Fulminant (hypotension or shock, ileus, or megacolon) CDI: Vancomycin 500 mg every 6 hours by mouth or nasogastric tube, combined with IV metronidazole 500 mg every 8 hours. In patients with ileus, consider adding rectal vancomycin 500 mg every 6 hours in 100 mL normal saline as a retention enema. […] In a multicenter retrospective (2013-2014) study of CDI in 72 Spanish patients, fidaxomicin treatment was effective and well tolerated in patients with severe CDI as well as those at high risk of recurrent disease. The clinical cure rate was 90.3%, with a 16.7% recurrence and a 72.2% sustained cure.

• #17 Biliary Tract Disorders, Gallbladder Disorders, & Gallstone Pancreatitis | ACG

  https://gi.org/topics/c-difficile-infection/

  First, it would be ideal to stop the antibiotic that led to the infection in the first place. This may not always be possible, however, as some infections, like severe bone or heart infections, need long-term antibiotics. Treatment for C. difficile is based on the severity of the infection. The current guidelines separate C. difficile infection into 3 categories: non-severe, severe and fulminant. Non-severe infections are usually treated in the outpatient setting. The standard of care treatment is vancomycin 125mg, four times a day for ten days or fidaxomicin 200mg, twice a day for ten days. The vast majority of patients will have resolution of symptoms after appropriate treatment. If diarrhea does not improve with appropriate antibiotics, an alternative diagnosis for diarrhea should be considered. Antidiarrheal drugs are not recommended to treat C. difficile infection and should only be used in consultation with your physician.

• #18 Biliary Tract Disorders, Gallbladder Disorders, & Gallstone Pancreatitis | ACG

  https://gi.org/topics/c-difficile-infection/

  Severe infections are diagnosed based on laboratory data including elevated white blood cell count (>15,000) and worsening kidney function (Creatinine >1.5). These patients are typically very sick with fever, abdominal pain, tenderness and dehydration and are often hospitalized. Similar to non-severe infections, patients with severe C. difficile infection should be treated with vancomycin 125mg, four times per day for 10 days or fidaxomicin 200mg, twice a day for ten days. […] Fulminant infections are defined by the presence of shock, low blood pressure, or toxic megacolon. Toxic megacolon is where the large intestine is dilated and at risk of perforating. These patients are at high risk of dying from their infection. Treatment includes higher doses of vancomycin 500mg four times per day. These patients often require intensive care monitoring and consultation with a surgeon as surgery to remove the colon may be needed to save the person’s life.

• #19 Current Treatment Options for Severe Clostridium difficile–associated Disease

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3088840/

  Thus, vancomycin is now recommended for initial therapy of severe disease. Although the standard regimen for vancomycin is 125 mg orally four times daily, in our experience, some severely ill patients require higher doses of 250 mg or even 500 mg orally four times daily. […] In such ill patients, adjunct therapies such as intravenous (IV) metronidazole may be helpful. […] In the fall of 2007, Cohen presented new Infectious Diseases Society of America guidelines, soon to be published, for treatment of severe and complicated CDAD. Severe CDAD is defined as patients having a white blood cell count greater than 15,000 cells/L and/or a 50% rise in serum creatinine. In these patients, the guidelines recommend initial therapy with vancomycin 125 mg four times daily. Complicated CDAD is defined as the presence of one or more of the following factors: hypotension, ileus, toxic megacolon, need for ICU admission or colectomy, or colonic perforation. In these patients, if complete ileus is not present, the guidelines recommend vancomycin 500 mg four times a day orally or per nasogastric tube and/or IV metronidazole 500-750 mg every 8 hours. For patients with a complete ileus, the recommendations include IV metronidazole and rectal vancomycin (500 mg in 100 mL of normal saline every 6 hours via rectal Foley tube).

• #20 Clostridioides difficile infection – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK431054/

  Fecal transplantation, involving the introduction of fecal matter from a healthy donor into the patient’s gastrointestinal tract, has reported an 80% to 90% success rate in reducing C difficile recurrence. […] For patients with recurrent C difficile infections, fidaxomicin is the preferred treatment option in a standard or extended-pulsed regimen, if available, as ESCMID recommends. […] Treatment options for a second or subsequent recurrence of C difficile infections include a taper and pulsed vancomycin regimen. […] For an initial fulminant episode with hypotension, shock, ileus, or megacolon, the treatment options include oral fidaxomicin 200 mg PO bid or oral vancomycin 500 mg every 6 hours orally or via a nasogastric tube if ileus is present.

• #21 Clostridioides (Clostridium) Difficile Colitis Treatment & Management: Approach Considerations, Pharmacologic Management, Fecal Microbiota Transplantation

  https://emedicine.medscape.com/article/186458-treatment

  Initial treatment: Treatment with fidaxomicin 200 mg by mouth twice a day for 10 days. If fidaxomicin is not available, then use oral vancomycin 125 mg by mouth four times a day for 10 days as an alternative. In nonsevere CDI (white blood cell [WBC] count 15,000 cells/uL and creatinine level 1.5 mg/dL), if fidaxomicin and vancomycin are not available, then use metronidazole 500 mg every 8 hours for 10-14 days. […] Fulminant (hypotension or shock, ileus, or megacolon) CDI: Vancomycin 500 mg every 6 hours by mouth or nasogastric tube, combined with IV metronidazole 500 mg every 8 hours. In patients with ileus, consider adding rectal vancomycin 500 mg every 6 hours in 100 mL normal saline as a retention enema. […] In a multicenter retrospective (2013-2014) study of CDI in 72 Spanish patients, fidaxomicin treatment was effective and well tolerated in patients with severe CDI as well as those at high risk of recurrent disease. The clinical cure rate was 90.3%, with a 16.7% recurrence and a 72.2% sustained cure.

• #22 Current Treatment Options for Severe Clostridium difficile–associated Disease

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3088840/

  A notable trend toward severe Clostridium difficile colitis and poor outcomes has emerged since recognition of the hyper-virulent C. difficile NAP1/027 strain. This trend has increased the emphasis on appropriate treatment regimens in refractory cases of C. difficile infection. In mild-to-moderate cases, oral metronidazole remains adequate first-line therapy, but in the absence of a good clinical response, switching to vancomycin may be necessary. Oral vancomycin should be used as initial therapy in severely ill patients or patients who cannot tolerate metronidazole. Rectal administration of vancomycin may be used as adjunctive therapy for severely ill patients. Patients with an ileus who cannot tolerate oral medications may improve with adjunct intravenous metronidazole and/or rectal vancomycin. Early surgical consultation should be requested, as some patients will require emergent colectomy.

• #23 About C. diff | C. diff | CDC

  https://www.cdc.gov/c-diff/about/index.html

  Treatment for C. diff infection usually involves taking a specific antibiotic such as vancomycin or fidaxomicin for at least 10 days. […] If you were taking an antibiotic for another infection, a healthcare professional might ask you to stop taking it if they think it’s safe to do so. […] The healthcare team might admit you to the hospital. In this case, they will use certain precautions, like wearing gowns and gloves to prevent the spread of C. diff infection to themselves and other patients. […] For those with repeat infections, innovative treatments, including fecal microbiota transplants, have shown promising results.

• #24 Clostridioides (Clostridium) Difficile Colitis: Background, Etiology, Pathophysiology

  https://emedicine.medscape.com/article/186458-overview

  Once infected with C difficile, the rate of disease recurrence is 20-40% when using metronidazole and vancomycin antibiotics as first-line therapy. […] Fidaxomicin is now recommended as first-line treatment due to a lower risk of CDI recurrence. […] In patients with CDI who develop fulminant colitis, early surgical consultation is crucial. […] The use of oral metronidazole or vancomycin produces response rates of greater than 95% in mild to moderate cases, with symptomatic improvement (diarrhea) in as little as 3-4 days and complete resolution in 7-10 days. […] However, approximately 20-27% of patients treated for a first episode of C difficile colitis relapse after successfully completing therapy, typically 3 days to 3 weeks after treatment has ended. […] Patients who relapse once are at an even greater risk for further relapses; the relapse rate for patients with 2 or more relapses is 65%.

• #25 Biliary Tract Disorders, Gallbladder Disorders, & Gallstone Pancreatitis | ACG

  https://gi.org/topics/c-difficile-infection/

  While antibiotics are effective in treating most cases of CDI, the symptoms recur after the end of treatment in 10-20% of cases. This is called recurrent CDI and usually occurs 1–2 weeks after stopping treatment. After a recurrence, the chance of further recurrences goes up to 40-60%, perhaps because one is using an antibiotic to treat a disease caused by antibiotics. We presume that the normal colonic bacteria have not had a chance to recolonize. Current recommendations for the treatment of recurrent CDI include a vancomycin taper over six to eight weeks or fidaxomicin for ten days. Bezlotuxumab is a recently approved drug to prevent recurrent infections and is given as a one-time IV infusion during a course of antibiotics for CDI. The most effective treatment, however, is fecal microbiota transplant (FMT). FMT is typically administered via colonoscopy where stool from a healthy donor is instilled into the colon of a patient with recurrent CDI. In studies, it has been effective in over 90% of patients who received the treatment, and has been proven effective with several randomized controlled trials. There are ongoing clinical trials using oral encapsulated forms of FMT, which are the future of this “drug.”

• #26 Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by SHEA/IDSA

  https://www.idsociety.org/practice-guideline/clostridium-difficile/

  For fulminant CDI, vancomycin administered orally is the regimen of choice (strong recommendation, moderate quality of evidence). If ileus is present, vancomycin can also be administered per rectum (weak recommendation, low quality of evidence). […] Treat a first recurrence of CDI with oral vancomycin as a tapered and pulsed regimen rather than a second standard 10-day course of vancomycin (weak recommendation, low quality of evidence), or treat a first recurrence of CDI with a 10-day course of fidaxomicin rather than a standard 10-day course of vancomycin (weak recommendation, moderate quality of evidence). […] Fecal microbiota transplantation is recommended for patients with multiple recurrences of CDI who have failed appropriate antibiotic treatments (strong recommendation, moderate quality of evidence).

• #27 Updated Clinical Practice Guidelines for C difficile Infection in Adults

  https://www.uspharmacist.com/article/updated-clinical-practice-guidelines-for-c-difficile-infection-in-adults

  The IDSA-SHEA guidelines suggest fidaxomicin as the preferred agent for treating initial CDI, with oral vancomycin considered an acceptable alternative. […] The IDSA-SHEA guidelines state that fidaxomicin for 10 days at a standard dosing regimen is the preferred treatment for an initial episode of CDI; this recommendation is conditional, with a moderate certainty of evidence. Oral vancomycin for 10 days at a standard dosing regimen is an acceptable alternative. […] The IDSA-SHEA guidelines suggest using fidaxomicin as a standard or extended-pulsed dosing regimen over vancomycin in patients with a first recurrence of CDI; this is a conditional recommendation with a low certainty of evidence. The guidelines also state that vancomycin (either standard dosing or a tapered and pulsed regimen) is an acceptable alternative.

• #28 Reddit – The heart of the internet

  https://www.reddit.com/r/cdifficile/comments/emv1rp/so_youve_been_diagnosed_with_c_difficile_what_now/

  VANCOMYCIN is currently the first line of treatment for cdiff. It kills less of your native flora than Flagyl, which gives your native flora a better chance of repopulating faster than the spores can germinate again. Vancomycin also has less side effects than Flagyl. […] DIFICID (also called Fidaxomycin) is the most effective drug for treating cdiff. It disturbs even less flora than Vancomycin, and it is also capable of killing spores. This drug is notoriously expensive, however, so your insurance may not cover it and doctors tend to prescribe it only if Vancomycin does not work. […] If a round of Flagyl or Vancomycin does not work, your doctor will likely recommend a Vancomycin or Dificid taper. This is when you take the drug for a long period of time, usually a few weeks, and gradually taper off to give your gut flora a chance to repopulate, while still discouraging cdiff spores from germinating. Pulsed tapers are a similar method.

• #29 VASF Clostridioides Difficile Infection (CDI) Treatment Guidelines | Infectious Diseases Management Program at UCSF

  https://idmp.ucsf.edu/content/vasf-clostridioides-difficile-infection-cdi-treatment-guidelines

  C. difficile Treatment Regimens […] Initial episode […] Vancomycin 125 mg PO q6h for 10 days […] OR […] Fidaxomicin 200 mg PO q12h for 10 days for patients at increased risk of CDI recurrence (at least 1): […] Age 65 years old, immunosuppression, history of inflammatory bowel disease […] Concomitant antibiotic use during CDI treatment […] 1st Recurrence Fidaxomicin 200 mg PO q12h for 10 days […] 2nd Recurrence […] Vancomycin oral solution in a tapered regimen: […] Vancomycin PO 125mg PO q6h x14 days, then 125mg PO q12h x7 days, then 125mg PO daily x7 days, then 125mg PO every other day x7 days, then 125mg every 3rd day x14 days […] PLUS […] Evaluate for fecal microbiota transplant (FMT), consider ID or GI consult […] Fulminant […] Vancomycin 500mg PO q6h […] If ileus is present, add metronidazole 500mg IV q8h and consider Vancomycin 500mg in 100ml normal saline given as a retention enema q6h.

• #30 Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by SHEA/IDSA

  https://www.idsociety.org/practice-guideline/clostridium-difficile/

  For fulminant CDI, vancomycin administered orally is the regimen of choice (strong recommendation, moderate quality of evidence). If ileus is present, vancomycin can also be administered per rectum (weak recommendation, low quality of evidence). […] Treat a first recurrence of CDI with oral vancomycin as a tapered and pulsed regimen rather than a second standard 10-day course of vancomycin (weak recommendation, low quality of evidence), or treat a first recurrence of CDI with a 10-day course of fidaxomicin rather than a standard 10-day course of vancomycin (weak recommendation, moderate quality of evidence). […] Fecal microbiota transplantation is recommended for patients with multiple recurrences of CDI who have failed appropriate antibiotic treatments (strong recommendation, moderate quality of evidence).

• #31 Biliary Tract Disorders, Gallbladder Disorders, & Gallstone Pancreatitis | ACG

  https://gi.org/topics/c-difficile-infection/

  While antibiotics are effective in treating most cases of CDI, the symptoms recur after the end of treatment in 10-20% of cases. This is called recurrent CDI and usually occurs 1–2 weeks after stopping treatment. After a recurrence, the chance of further recurrences goes up to 40-60%, perhaps because one is using an antibiotic to treat a disease caused by antibiotics. We presume that the normal colonic bacteria have not had a chance to recolonize. Current recommendations for the treatment of recurrent CDI include a vancomycin taper over six to eight weeks or fidaxomicin for ten days. Bezlotuxumab is a recently approved drug to prevent recurrent infections and is given as a one-time IV infusion during a course of antibiotics for CDI. The most effective treatment, however, is fecal microbiota transplant (FMT). FMT is typically administered via colonoscopy where stool from a healthy donor is instilled into the colon of a patient with recurrent CDI. In studies, it has been effective in over 90% of patients who received the treatment, and has been proven effective with several randomized controlled trials. There are ongoing clinical trials using oral encapsulated forms of FMT, which are the future of this “drug.”

• #32 C. difficile infection – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/c-difficile/diagnosis-treatment/drc-20351697

  Antibody-based therapy. A therapy known as bezlotoxumab (Zinplava) is a human antibody against C. difficile toxin B. It has been shown to cut the risk of repeat C. difficile infection in those at high risk of repeat episodes. […] Fecal microbiota transplant (FMT). FMT is a newer treatment for C. difficile infection that keeps coming back. FMT has been studied in clinical trials. The U.S. Food and Drug Administration has not approved FMT but allows the use of FMT for C. difficile infection as a test. […] Research has shown that FMT done one or more times has a success rate higher than 85% for treating C. difficile infections that keep coming back. […] Probiotics are supplements or foods that have microorganisms to keep or improve the „good” bacteria in the body. The role of these products in C. difficile infection is not clear. Not all the research has shown that probiotics are helpful in preventing or treating infection with C. difficile.

• #33 Clostridioides difficile infection – Wikipedia

  https://en.wikipedia.org/wiki/Clostridioides_difficile_infection

  Treatment Metronidazole, vancomycin, fidaxomicin, fecal microbiota transplantation […] The antibiotics metronidazole, vancomycin, or fidaxomicin, will cure the infection. […] Vancomycin or fidaxomicin by mouth are the typically recommended for mild, moderate, and severe infections. […] Typical vancomycin 125 mg is taken four times a day by mouth for 10 days. […] Fidaxomicin is taken at 200 mg twice daily for 10 days. […] Fidaxomicin has been found to be as effective as vancomycin in those with mild to moderate disease, and it may be better than vancomycin in those with severe disease. […] Fecal microbiota transplant, also known as a stool transplant, is roughly 85% to 90% effective in those for whom antibiotics have not worked. […] In those with severe C. difficile colitis, colectomy may improve the outcomes. […] Several treatment options exist for recurrent C. difficile infection. […] For patients with C. diff infections that fail to be resolved with traditional antibiotic regimens, fecal microbiome transplants boasts an average cure rate of 90%.

• #34 Clostridioides (Clostridium) Difficile Colitis Treatment & Management: Approach Considerations, Pharmacologic Management, Fecal Microbiota Transplantation

  https://emedicine.medscape.com/article/186458-treatment

  In fulminant cases, combined therapy with IV metronidazole and vancomycin (PO or PR) is the treatment of choice. IV vancomycin is ineffective and should not be used for C difficile. […] FMT is a novel therapy that involves the transfer of stool from a healthy donor to a patient with CDI to reconstitute the normal colonic microbial flora. It is given after treating CDI with antibiotics. Studies have evaluated prevention of recurrence of CDI after FMT. […] Several studies have shown that FMT by colonoscopy or enema was an effective approach for patients with recurrent CDI, with clinical success rates of up to 95%. […] In November 2022, the FDA approved microbiota via rectal administration (Rebyota) for prevention of recurrence of CDI in adults following antibiotic treatment for CD recurrence.

• #35 Recommendations | Clostridioides difficile infection: antimicrobial prescribing | Guidance | NICE

  https://www.nice.org.uk/guidance/ng199/chapter/Recommendations

  The recommendations in this guideline update existing Public Health England guidance on treating Clostridioides difficile infection. […] For adults, offer an oral antibiotic to treat suspected or confirmed C. difficile infection (see the recommendations on choice of antibiotic). In the community, consider seeking prompt specialist advice from a microbiologist or infectious diseases specialist before starting treatment. […] For people with suspected or confirmed C. difficile infection who cannot take oral medicines, seek specialist advice from a gastroenterologist or pharmacist about alternative enteral routes for antibiotics, such as a nasogastric tube or rectal catheter. […] Do not offer bezlotoxumab to prevent recurrence of C. difficile infection because it is not cost effective. […] Consider a faecal microbiota transplant for a recurrent episode of C. difficile infection in adults who have had 2 or more previous episodes. […] When prescribing antibiotics for suspected or confirmed C. difficile infection in adults, follow table 1. […] Do not offer antibiotics to prevent C. difficile infection. […] Do not advise people taking antibiotics to take prebiotics or probiotics to prevent C. difficile infection.

• #36 Advances in Therapeutic Strategies for the Management of Clostridioides difficile Infection

  https://www.mdpi.com/2077-0383/13/5/1331

  The use of monoclonal antibodies can be an alternative strategy to antibiotics for CDI treatment. Bezlotoxumab is a monoclonal antibody already used in clinical practice, indicated for the prevention of recurrent CDI (rCDI) as it provides passive immunity against the toxin produced by the development of persistent or newly acquired C. difficile spores. […] Faecal microbiota transplantation (FMT) consists of the infusion of faeces from a healthy donor to the GI tract of a recipient patient in order to treat a specific disease associated with an alteration of the gut microbiota, e.g., ulcerative colitis (UC) and metabolic syndrome. Numerous pieces of evidence have clearly demonstrated that FMT is a highly effective treatment against rCDI. […] The use of monoclonal antibodies or FMTs is of enormous importance in reducing the risk of rCDI.

• #37 Treatment Options – Peggy Lillis Foundation

  https://cdiff.org/treatment-options/

  Another type of therapy for C. diff is microbiome restoration, which may be prescribed to help prevent recurrence (getting sick with C. diff again) after antibiotics have already been used to fight your infection. […] Fecal transplants involve the insertion of donor stool tested for safety, strained, and mixed with a sterile salt solution, into a patient, typically via colonoscopy (the most common method), enema, nasogastric (NG) tube, or oral capsule. […] REBYOTA was approved in November of 2022 by the FDA to prevent C. diff recurrence. […] Vowst is also a microbiota-based product, approved in April of 2023 by FDA for the prevention of recurrence, that is taken orally in capsule form. […] It may take some time for these newer therapies to be added to clinical practice guidelines for C. diff.

• #38 Clostridioides (Clostridium) Difficile Colitis Treatment & Management: Approach Considerations, Pharmacologic Management, Fecal Microbiota Transplantation

  https://emedicine.medscape.com/article/186458-treatment

  In fulminant cases, combined therapy with IV metronidazole and vancomycin (PO or PR) is the treatment of choice. IV vancomycin is ineffective and should not be used for C difficile. […] FMT is a novel therapy that involves the transfer of stool from a healthy donor to a patient with CDI to reconstitute the normal colonic microbial flora. It is given after treating CDI with antibiotics. Studies have evaluated prevention of recurrence of CDI after FMT. […] Several studies have shown that FMT by colonoscopy or enema was an effective approach for patients with recurrent CDI, with clinical success rates of up to 95%. […] In November 2022, the FDA approved microbiota via rectal administration (Rebyota) for prevention of recurrence of CDI in adults following antibiotic treatment for CD recurrence.

• #39 Breaking the cycle: New treatments for recurrent C diff offer an alternative to repeated antibiotics | CIDRAP

  https://www.cidrap.umn.edu/antimicrobial-stewardship/breaking-cycle-new-treatments-recurrent-c-diff-offer-alternative-repeated

  Over the past year, two more treatments for rCDI that could help break the antibiotic/recurrence cycle have come on the market. In November 2022, the FDA approved Rebyota, a fecal microbiota-based product that is prepared from stool donated by qualified individuals and delivered via enema. […] Then, in April of this year, the FDA approved Vowst, an oral drug developed by Seres Therapeutics that contains live bacteria from human fecal matter. […] The randomized controlled trials that led to the approval of the two microbiota-based drugswhich are technically considered preventivesshowed that both significantly cut CDI recurrence compared with the standard-of-care antibiotic treatments or placebo and were well-tolerated. […] „If we could get to the point where we have a standard-of-care that doesn’t allow people to go 6 months or more of just being bounced from one antibiotic to the otherthat would be ideal,” Lillis said. „I think you would interrupt that cycle.”

• #40 Clostridioides (Clostridium) Difficile Colitis Treatment & Management: Approach Considerations, Pharmacologic Management, Fecal Microbiota Transplantation

  https://emedicine.medscape.com/article/186458-treatment

  A second orally administered microbiota product (Vowst) received FDA approval in April 2023. Results from the ECOSPOR III phase 3 double-blind, randomized, placebo-controlled trial showed a decreased recurrence of CDI in patients treated orally with microbiota compared with placebo (12% vs 40%, respectively; P 0.001).

• #41 Managing Recurrent C difficile Infections: Past, Present, and Future

  https://www.pharmacytimes.com/view/managing-recurrent-c-difficile-infections-past-present-and-future

  Fecal microbiota transplant (FMT) is also recommended in patients with multiple recurrences of CDI. FMT involves transferring processed stool from a healthy donor and introducing it into the colon of the patient with recurrent CDI. Introduction of healthy gut bacteria allows for colonization and competition against C difficile bacteria, helping to prevent recurrence. […] Two FMT-based therapeutics have been recently approved by the FDA. Fecal microbiota, live-jslm (Rebyota; Ferring Pharmaceuticals) was approved in November 2022; it is a suspension to be given rectally. Fecal microbiota spores, live-brpk (Vowst; Seres Therapeutics) was approved in April 2023; it is an orally administered capsule. Both are indicated for the prevention of recurrence of CDI in individuals 18 years and older.

• #42 C. difficile infection – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/c-difficile/diagnosis-treatment/drc-20351697

  Antibody-based therapy. A therapy known as bezlotoxumab (Zinplava) is a human antibody against C. difficile toxin B. It has been shown to cut the risk of repeat C. difficile infection in those at high risk of repeat episodes. […] Fecal microbiota transplant (FMT). FMT is a newer treatment for C. difficile infection that keeps coming back. FMT has been studied in clinical trials. The U.S. Food and Drug Administration has not approved FMT but allows the use of FMT for C. difficile infection as a test. […] Research has shown that FMT done one or more times has a success rate higher than 85% for treating C. difficile infections that keep coming back. […] Probiotics are supplements or foods that have microorganisms to keep or improve the „good” bacteria in the body. The role of these products in C. difficile infection is not clear. Not all the research has shown that probiotics are helpful in preventing or treating infection with C. difficile.

• #43 Updated Clinical Practice Guidelines for C difficile Infection in Adults

  https://www.uspharmacist.com/article/updated-clinical-practice-guidelines-for-c-difficile-infection-in-adults

  Recommended treatment of fulminant CDI (characterized by hypotension or shock, ileus, or megacolon) has not changed from the previous version of the guidelines. Importantly, there is no current evidence to support the use of fidaxomicin for fulminant infections, so this agent is not recommended for fulminant CDI. […] Bezlotoxumab is a humanized monoclonal antibody that binds to and neutralizes C difficile toxin B. It was approved in 2016 as a single-dose infusion in conjunction with antibiotic therapy for CDI to reduce recurrent CDI in adults at high risk for recurrence. […] The IDSA-SHEA guidelines suggest the addition of bezlotoxumab to antibiotic therapy (given at any time during antibiotic therapy) in patients who had a CDI recurrence within the previous 6 months. […] The updated ACG guidelines state that the use of oral vancomycin as prophylaxis (to prevent recurrence) may be considered in patients with a recent history of CDI who require antibiotic treatment and are at high risk for recurrent infection (i.e., aged 65 years or older or significantly immunocompromised and hospitalized within the previous 3 months for severe CDI); this is a conditional recommendation with a low quality of evidence.

• #44 Treating C. Difficile: Medicine to Prevent a Repeat Infection | Saint Luke’s Health System

  https://www.saintlukeskc.org/health-library/treating-c-difficile-medicine-prevent-repeat-infection

  To treat a C. diff infection, your healthcare provider might have you stop taking the antibiotic that caused the C. diff to multiply, if possible. You will likely be given a different antibiotic to treat the C. diff. Treatment for C. diff stops the symptoms. […] If you are being treated for C. diff and are at risk for a relapse, your provider may prescribe an additional medicine. This medicine is called bezlotoxumab. In some people, it can lower the chance of the symptoms coming back. […] Bezlotoxumab has been shown to lower the risk of recurrent C. diff by about 10%. […] The medicine is a human monoclonal antibody. […] Bezlotoxumab does not treat the infection or kill the bacteria. So it’s only used along with the antibiotic medicine used to treat C. diff. […] Bezlotoxumab is a liquid medicine that is given through an IV (intravenous) line into a vein. A healthcare provider will put a needle into a vein in your arm or hand. A thin, flexible tube (catheter) is then put into the vein. The medicine drips slowly through the tube into your vein. It takes about 1 hour to complete the treatment. You get this treatment just one time while you are taking the antibiotics.

• #45 Updated Clinical Practice Guidelines for C difficile Infection in Adults

  https://www.uspharmacist.com/article/updated-clinical-practice-guidelines-for-c-difficile-infection-in-adults

  Recommended treatment of fulminant CDI (characterized by hypotension or shock, ileus, or megacolon) has not changed from the previous version of the guidelines. Importantly, there is no current evidence to support the use of fidaxomicin for fulminant infections, so this agent is not recommended for fulminant CDI. […] Bezlotoxumab is a humanized monoclonal antibody that binds to and neutralizes C difficile toxin B. It was approved in 2016 as a single-dose infusion in conjunction with antibiotic therapy for CDI to reduce recurrent CDI in adults at high risk for recurrence. […] The IDSA-SHEA guidelines suggest the addition of bezlotoxumab to antibiotic therapy (given at any time during antibiotic therapy) in patients who had a CDI recurrence within the previous 6 months. […] The updated ACG guidelines state that the use of oral vancomycin as prophylaxis (to prevent recurrence) may be considered in patients with a recent history of CDI who require antibiotic treatment and are at high risk for recurrent infection (i.e., aged 65 years or older or significantly immunocompromised and hospitalized within the previous 3 months for severe CDI); this is a conditional recommendation with a low quality of evidence.

• #46 C. difficile infection – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/c-difficile/diagnosis-treatment/drc-20351697

  Antibody-based therapy. A therapy known as bezlotoxumab (Zinplava) is a human antibody against C. difficile toxin B. It has been shown to cut the risk of repeat C. difficile infection in those at high risk of repeat episodes. […] Fecal microbiota transplant (FMT). FMT is a newer treatment for C. difficile infection that keeps coming back. FMT has been studied in clinical trials. The U.S. Food and Drug Administration has not approved FMT but allows the use of FMT for C. difficile infection as a test. […] Research has shown that FMT done one or more times has a success rate higher than 85% for treating C. difficile infections that keep coming back. […] Probiotics are supplements or foods that have microorganisms to keep or improve the „good” bacteria in the body. The role of these products in C. difficile infection is not clear. Not all the research has shown that probiotics are helpful in preventing or treating infection with C. difficile.

• #47 CDI Treatment Clostridioides (Clostridium) difficile Toolkit for Long-term Care Facilities – MN Dept. of Health

  https://www.health.state.mn.us/diseases/cdiff/hcp/ltctoolkit/treatment.html

  Transplanting stool from a healthy person to the colon of a patient with repeat C. difficile infections has been shown to successfully treat C. difficile. These fecal transplants appear to be the most effective method for helping patients with repeat C. difficile infections. This procedure may not be widely available and its long-term safety has not been established. […] Probiotics are not recommended to prevent primary CDI due to limited data and risk of bloodstream infection. Patients with recurrent CDI may benefit from 500 mg of Saccharomyces boulardii twice a day.

• #48 Clostridium difficile Infection: Prevention and Treatment | AAFP

  https://www.aafp.org/pubs/afp/issues/2018/0201/p196.html

  Antibiotic stewardship and handwashing campaigns reduce C. difficile infection without reported harms. (Strength of Recommendation [SOR]: B, based on inconsistent or limited-quality patient-oriented evidence.) Vancomycin has a higher initial cure rate than metronidazole, although the recurrence rate is equal between the two drugs. Fidaxomicin has a lower recurrence rate than vancomycin, although there is no difference in the initial cure rate. (SOR: B, based on inconsistent or limited-quality patient-oriented evidence.) There is low strength but consistent evidence that Lactobacillus, multiorganism probiotics, and fecal microbiota transplantation are effective in reducing C. difficile infection recurrence. […] Regarding treatment, this AHRQ review found high strength of evidence based on four RCTs that oral vancomycin has higher initial C. difficile infection cure rates compared with metronidazole (83.9% vs. 75.7%; number needed to treat [NNT] = 12; 95% confidence interval [CI], 7 to 35), and no difference between fidaxomicin and vancomycin in initial cure. When assessing C. difficile infection recurrence rates, fidaxomicin is favored over vancomycin (14.1% vs. 26.1%; NNT = 8; 95% CI, 6 to 15), and there is no difference between vancomycin and metronidazole.

• #49 CDI Treatment Clostridioides (Clostridium) difficile Toolkit for Long-term Care Facilities – MN Dept. of Health

  https://www.health.state.mn.us/diseases/cdiff/hcp/ltctoolkit/treatment.html

  Transplanting stool from a healthy person to the colon of a patient with repeat C. difficile infections has been shown to successfully treat C. difficile. These fecal transplants appear to be the most effective method for helping patients with repeat C. difficile infections. This procedure may not be widely available and its long-term safety has not been established. […] Probiotics are not recommended to prevent primary CDI due to limited data and risk of bloodstream infection. Patients with recurrent CDI may benefit from 500 mg of Saccharomyces boulardii twice a day.

• #50 Reddit – The heart of the internet

  https://www.reddit.com/r/cdifficile/comments/emv1rp/so_youve_been_diagnosed_with_c_difficile_what_now/

  If Vancomycin, Dificid, and taper methods all fail, there is still one option and strangely enough, it is the most effective: a fecal transplant (also called FMT). This method involves taking stool from a healthy donor and transplanting into your gut. Although it sounds disgusting, fecal transplants have a success rate of over 90% when used to treat cdiff. […] The only way to manage PI-IBS is to figure out which foods are irritating your gut. […] The probiotic Florastor (generic name: saccharomyces boulardii) is the gold standard for preventing cdiff recurrence and easing PI-IBS symptoms. Your doctor may recommend that you take it 1-4x a day for weeks or months after your infection, or even indefinitely if you’re high-risk (existing problems like IBS, Crohns, GERD, etc.)

• #51 C. difficile infection – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/c-difficile/diagnosis-treatment/drc-20351697

  Treatments are used only for symptoms of infection. People who carry the bacteria but aren’t sick don’t get treated. […] Antibiotics are the main treatment for C. difficile infection. Commonly used antibiotics include: Vancomycin (Firvanq Kit), Fidaxomicin (Dificid). […] Metronidazole (Flagyl) may be used with vancomycin to treat serious C. difficile infection. […] Surgery to remove the diseased part of the colon may be needed if there’s: Severe pain, Organ failure, Toxic megacolon, Swelling and irritation, called inflammation, of the lining of the wall around the stomach area. […] Treatment for C. difficile infection that comes back might include the following: Antibiotics. Treatment for repeat infections may involve one or more courses of an antibiotic. The antibiotic is often different from the one used at first. Antibiotic therapy works less well each time the infection comes back.

• #52 C. diff Infection: What It Is, Symptoms & Treatment

  https://my.clevelandclinic.org/health/diseases/15548-c-diff-infection

  If you have severe complications, you might need intensive care. In rare cases, providers recommend emergency surgery to remove the source of the infection in your colon. This is called colectomy. […] If you’ve recovered but you continue to have repeat infections after treatment, your options are: Repeat antibiotic therapy. Your provider may give you a different drug, or a longer prescription for the same drug. After antibiotics, your provider may recommend that you take probiotics to help restore your gut bacteria. […] Fecal microbiota transplant. When repeat antibiotic therapy fails, fecal transplantation has proved highly effective in preventing recurrent C. diff infection. Fecal transplantation involves transferring a poop sample from a healthy donor into a diseased colon. The sample will restore balance to your gut microbiome.

• #53 Consensus on the prevention, diagnosis, and treatment of Clostridium difficile infection | Revista de Gastroenterología de México

  https://www.revistagastroenterologiamexico.org/en-consensus-on-prevention-diagnosis-treatment-articulo-S2255534X19300295

  In cases of complicated severe CDI, treatment should be oral vancomycin combined with intravenous metronidazole. […] Other antimicrobial treatment alternatives for CDI are: fidaxomicin, rifaximin-alpha, and nitazoxanide. […] For the treatment of the first recurrence of CDI, vancomycin is recommended if the patient received metronidazole. If vancomycin was prescribed, retreatment with vancomycin is recommended, followed by tapering doses, and ending with pulsed doses. […] Fecal microbiota transplantation is a safe and effective option in patients with CDI with two recurrences or in patients with severe episodes and antimicrobial treatment failure. […] Surgery should be reserved for patients with severe colitis (toxic megacolon) that have had failure with all medical treatment, failed FMT, generalized peritonitis, or the rare cases of colonic perforation.

• #54 C. difficile infection – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/c-difficile/diagnosis-treatment/drc-20351697

  Treatments are used only for symptoms of infection. People who carry the bacteria but aren’t sick don’t get treated. […] Antibiotics are the main treatment for C. difficile infection. Commonly used antibiotics include: Vancomycin (Firvanq Kit), Fidaxomicin (Dificid). […] Metronidazole (Flagyl) may be used with vancomycin to treat serious C. difficile infection. […] Surgery to remove the diseased part of the colon may be needed if there’s: Severe pain, Organ failure, Toxic megacolon, Swelling and irritation, called inflammation, of the lining of the wall around the stomach area. […] Treatment for C. difficile infection that comes back might include the following: Antibiotics. Treatment for repeat infections may involve one or more courses of an antibiotic. The antibiotic is often different from the one used at first. Antibiotic therapy works less well each time the infection comes back.

• #55 C. Diff Infection: Symptoms, Causes, Diagnosis and Treatment

  https://www.webmd.com/digestive-disorders/clostridioides-difficile-colitis

  Antibiotics may have triggered your infection, but some types of these drugs target C. diff. They include: Fidaxomicin, Metronidazole, Vancomycin. […] Talk with your doctor about the side effects of these antibiotics. It’s important to replace fluids that you lost from diarrhea. Drink plenty of fluids that have water, salt, and sugar, such as broth and fruit juices. […] If there’s been damage to your intestines, you may need surgery to remove the affected areas. […] Doctors sometimes recommend a treatment to help repopulate the colon with healthy bacteria. It’s often done by putting another person’s stool in your colon using a device called a colonoscope. The procedure is called fecal microbiota transplant (FMT). […] After having C. diff, it’s important to reintroduce „good” bacteria back into your gut. These bacteria, called probiotics, can help limit the growth of C. diff. Fermented foods with live cultures such as yogurt, kefir, miso, and sauerkraut contain probiotics. Probiotics can also be taken as supplements. […] There is limited evidence about the role probiotics play in helping to treat or prevent C. diff. Some data suggests that combinations of the good bacteria Lactobacillus and S. boulardii may help prevent C. diff infections in high-risk patients, but more research is needed.

• #56 Clostridioides difficile infection

  https://www.hse.ie/eng/services/list/2/gp/antibiotic-prescribing/conditions-and-treatments/gastro/clostridium-difficile/

  General measures advised in the treatment of patients with CDI: Patients/ residents of a healthcare facility with potentially infectious diarrhoea (i.e. no clear alternative cause) should be isolated with Standard and Contact Precautions as soon as possible. […] Stop unnecessary antimicrobial therapy (if possible). […] Ensure adequate nutrition and replacement of fluid and electrolytes. […] Avoid anti-motility medications. […] Review proton pump inhibitor use. […] If an antibiotic is still essential, consider changing to one with a lower risk of causing CDI. […] It is recommended to discontinue antibiotic therapy with the inciting antibiotic if possible and closely monitor the patient for 48 hours. C. difficile treatment should be initiated if any signs of clinical deterioration are observed.

• #57 CDI Treatment Clostridioides (Clostridium) difficile Toolkit for Long-term Care Facilities – MN Dept. of Health

  https://www.health.state.mn.us/diseases/cdiff/hcp/ltctoolkit/treatment.html

  Whenever possible, other antibiotics should be discontinued. In a small number of patients, diarrhea may go away when other antibiotics are stopped. Proton pump inhibitors (PPI) and antiperistaltic agents should also be avoided for all residents suspected of having or diagnosed with CDI. […] Treatment of primary infection caused by C. difficile is an antibiotic such as metronidazole, vancomycin, or fidaxomicin. While metronidazole is not approved for treating C. difficile infections by the FDA, it has been commonly recommended and used for mild C. difficile infections; however, it should not be used for severe C. difficile infections. Whenever possible, treatment should be given by mouth and continued for a minimum of 10 days. […] One problem with antibiotics used to treat primary C. difficile infection is that the infection returns in about 20 percent of patients. In a small number of these patients, the infection returns over and over and can be quite debilitating. While a first return of a C. difficile infection is usually treated with the same antibiotic used for primary infection, all future infections should be managed with oral vancomycin or fidaxomicin.

• #58 Clostridium Difficile (C. Diff): Symptoms and Treatment

  https://patient.info/digestive-health/clostridium-difficile-c-diff

  As with any cause for diarrhoea, it is important that you replace the fluids that are lost in the diarrhoea. […] In the small number of cases that progress into fulminant colitis, surgery may be needed, especially if the colon perforates. […] Antidiarrhoeal medicines such as loperamide should not be used if C. difficile infection is suspected. This is because it is thought that they may slow down the rate at which the poisons (toxins) produced by the bacteria are cleared from your gut. […] Probiotics are bacteria and yeasts that resemble the protective bacteria of the gut and they are also not recommended at present. This is because evidence that they are helpful in clearing the infection is lacking.

• #59 Updated Clinical Practice Guidelines for C difficile Infection in Adults

  https://www.uspharmacist.com/article/updated-clinical-practice-guidelines-for-c-difficile-infection-in-adults

  Recommended treatment of fulminant CDI (characterized by hypotension or shock, ileus, or megacolon) has not changed from the previous version of the guidelines. Importantly, there is no current evidence to support the use of fidaxomicin for fulminant infections, so this agent is not recommended for fulminant CDI. […] Bezlotoxumab is a humanized monoclonal antibody that binds to and neutralizes C difficile toxin B. It was approved in 2016 as a single-dose infusion in conjunction with antibiotic therapy for CDI to reduce recurrent CDI in adults at high risk for recurrence. […] The IDSA-SHEA guidelines suggest the addition of bezlotoxumab to antibiotic therapy (given at any time during antibiotic therapy) in patients who had a CDI recurrence within the previous 6 months. […] The updated ACG guidelines state that the use of oral vancomycin as prophylaxis (to prevent recurrence) may be considered in patients with a recent history of CDI who require antibiotic treatment and are at high risk for recurrent infection (i.e., aged 65 years or older or significantly immunocompromised and hospitalized within the previous 3 months for severe CDI); this is a conditional recommendation with a low quality of evidence.

• #60 Recurrent Clostridium difficile Infection: Risk Factors, Treatment, and Prevention

  https://www.gutnliver.org/journal/view.html?doi=10.5009/gnl18071

  Some case reports have shown that intravenous gamma globulin is effective for rCDI. However, additional large-scale studies are needed to confirm these results. […] Oral vancomycin for secondary prevention may reduce the risk of recurrence following antibiotic exposure in patients with a recent CDI history. […] Bezlotoxumab is considered to be useful as secondary prophylaxis for CDI.

• #61 Updated Clinical Practice Guidelines for C difficile Infection in Adults

  https://www.uspharmacist.com/article/updated-clinical-practice-guidelines-for-c-difficile-infection-in-adults

  Recommended treatment of fulminant CDI (characterized by hypotension or shock, ileus, or megacolon) has not changed from the previous version of the guidelines. Importantly, there is no current evidence to support the use of fidaxomicin for fulminant infections, so this agent is not recommended for fulminant CDI. […] Bezlotoxumab is a humanized monoclonal antibody that binds to and neutralizes C difficile toxin B. It was approved in 2016 as a single-dose infusion in conjunction with antibiotic therapy for CDI to reduce recurrent CDI in adults at high risk for recurrence. […] The IDSA-SHEA guidelines suggest the addition of bezlotoxumab to antibiotic therapy (given at any time during antibiotic therapy) in patients who had a CDI recurrence within the previous 6 months. […] The updated ACG guidelines state that the use of oral vancomycin as prophylaxis (to prevent recurrence) may be considered in patients with a recent history of CDI who require antibiotic treatment and are at high risk for recurrent infection (i.e., aged 65 years or older or significantly immunocompromised and hospitalized within the previous 3 months for severe CDI); this is a conditional recommendation with a low quality of evidence.

• #62 Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by SHEA/IDSA

  https://www.idsociety.org/practice-guideline/clostridium-difficile/

  Either metronidazole or vancomycin is recommended for the treatment of children with an initial episode or first recurrence of nonsevere CDI (weak recommendation, low quality of evidence). […] For children with an initial episode of severe CDI, oral vancomycin is recommended over metronidazole (strong recommendation, moderate quality of evidence). […] For children with a second or greater episode of recurrent CDI, oral vancomycin is recommended over metronidazole (weak recommendation, low quality of evidence). […] Consider fecal microbiota transplantation for pediatric patients with multiple recurrences of CDI following standard antibiotic treatments (weak recommendation, very low quality of evidence).

• #63 Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by SHEA/IDSA

  https://www.idsociety.org/practice-guideline/clostridium-difficile/

  Either metronidazole or vancomycin is recommended for the treatment of children with an initial episode or first recurrence of nonsevere CDI (weak recommendation, low quality of evidence). […] For children with an initial episode of severe CDI, oral vancomycin is recommended over metronidazole (strong recommendation, moderate quality of evidence). […] For children with a second or greater episode of recurrent CDI, oral vancomycin is recommended over metronidazole (weak recommendation, low quality of evidence). […] Consider fecal microbiota transplantation for pediatric patients with multiple recurrences of CDI following standard antibiotic treatments (weak recommendation, very low quality of evidence).

• #64 Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by SHEA/IDSA

  https://www.idsociety.org/practice-guideline/clostridium-difficile/

  Either metronidazole or vancomycin is recommended for the treatment of children with an initial episode or first recurrence of nonsevere CDI (weak recommendation, low quality of evidence). […] For children with an initial episode of severe CDI, oral vancomycin is recommended over metronidazole (strong recommendation, moderate quality of evidence). […] For children with a second or greater episode of recurrent CDI, oral vancomycin is recommended over metronidazole (weak recommendation, low quality of evidence). […] Consider fecal microbiota transplantation for pediatric patients with multiple recurrences of CDI following standard antibiotic treatments (weak recommendation, very low quality of evidence).

• #65 C. difficile infection – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/c-difficile/diagnosis-treatment/drc-20351697

  Treatments are used only for symptoms of infection. People who carry the bacteria but aren’t sick don’t get treated. […] Antibiotics are the main treatment for C. difficile infection. Commonly used antibiotics include: Vancomycin (Firvanq Kit), Fidaxomicin (Dificid). […] Metronidazole (Flagyl) may be used with vancomycin to treat serious C. difficile infection. […] Surgery to remove the diseased part of the colon may be needed if there’s: Severe pain, Organ failure, Toxic megacolon, Swelling and irritation, called inflammation, of the lining of the wall around the stomach area. […] Treatment for C. difficile infection that comes back might include the following: Antibiotics. Treatment for repeat infections may involve one or more courses of an antibiotic. The antibiotic is often different from the one used at first. Antibiotic therapy works less well each time the infection comes back.

• #66 Clostridioides (Clostridium) Difficile Colitis Treatment & Management: Approach Considerations, Pharmacologic Management, Fecal Microbiota Transplantation

  https://emedicine.medscape.com/article/186458-treatment

  The decision to treat C difficile infection (CDI) and the type of therapy administered depend on the severity of infection, as well as the local epidemiology and type of C difficile strains present. Except for perioperative prophylaxis, it is recommended that the use of cephalosporin and clindamycin be restricted for infection prevention. No treatment is necessary for asymptomatic carriers. […] For symptomatic patients, the Infectious Diseases Society of America (ISDA) and Society for Healthcare Epidemiology of America (SHEA) 2021 updated guideline for CDI treatment recommend administering fidaxomicin for initial and recurrent infections, with oral vancomycin as an alternative. Fecal microbiota transplantation (FMT) may also be added after treating the second recurrence. Bezlotoxumab had been recommended as adjunctive treatment for recurrent CDI, but it has been discontinued as of January 31, 2025.

• #67 Managing Recurrent C difficile Infections: Past, Present, and Future

  https://www.pharmacytimes.com/view/managing-recurrent-c-difficile-infections-past-present-and-future

  There are multiple investigational drugs in clinical trials for the treatment of recurrent CDI, including RBX7455 and VE303. RBX7455 is a human stool-derived FMT oral capsule, and VE303 is a synthetic oral capsule that contains 8 types of Clostridia bacteria species. […] Another promising area of treatment includes vaccines for CDI. One example is Pfizer’s PF-06425090, a toxoid-based vaccine. Although PF-06425090’s phase clinical trial (NCT03090191) has been halted, vaccines may play a role in the treatment of CDI in the future.

• #68 Advances in Therapeutic Strategies for the Management of Clostridioides difficile Infection

  https://www.mdpi.com/2077-0383/13/5/1331

  FMT can restore the variability of the gut’s bacterial composition and improve rCDI symptoms. […] The evidence on the most suitable treatments for the prevention of primary C difficile infections is currently unclear. […] Considering that C. difficile uses faecal–oral transmission as its main route, a mucosal vaccine generating IgA and IgG responses could prevent colonisation and disease. […] An oral microbiome therapy indicated to avoiding rCDI showed efficacy and safety. […] The safety and efficacy of RBX2660 were demonstrated in two multicentre and randomised studies: the pivotal PUNCH CD3 clinical trial and the phase 2b PUNCH CD2 study.

• #69 Recurrent Clostridium difficile Infection: Risk Factors, Treatment, and Prevention

  https://www.gutnliver.org/journal/view.html?doi=10.5009/gnl18071

  Some case reports have shown that intravenous gamma globulin is effective for rCDI. However, additional large-scale studies are needed to confirm these results. […] Oral vancomycin for secondary prevention may reduce the risk of recurrence following antibiotic exposure in patients with a recent CDI history. […] Bezlotoxumab is considered to be useful as secondary prophylaxis for CDI.

• #70 Clostridioides (Clostridium) Difficile Colitis Treatment & Management: Approach Considerations, Pharmacologic Management, Fecal Microbiota Transplantation

  https://emedicine.medscape.com/article/186458-treatment

  In patients with severe, complicated, or fulminant CDI (hypotension, shock, ileus or megacolon), oral (or via nasogastric tube) vancomycin 500 mg every 6 hours along with intravenous (IV) metronidazole is recommended. Rectal vancomycin may also be added in patients with ileus. […] Treatment recommendations for CDI have evolved over the past few years. One reason for change is the frequent relapse rate of CDI (20-27%). In 2021, the ISDA recommended using fidaxomicin first line for treatment of an initial CDI episode as well as subsequent recurrence. Relative to vancomycin, fidaxomicin is not only a more targeted intestinal antibiotic but also associated with fewer CDI recurrences. Vancomycin is still considered to be an acceptable alternative. However, metronidazole is no longer recommended unless fidaxomicin and vancomycin are not available.

• #71 Updated Clinical Practice Guidelines for C difficile Infection in Adults

  https://www.uspharmacist.com/article/updated-clinical-practice-guidelines-for-c-difficile-infection-in-adults

  The IDSA-SHEA guidelines suggest fidaxomicin as the preferred agent for treating initial CDI, with oral vancomycin considered an acceptable alternative. […] The IDSA-SHEA guidelines state that fidaxomicin for 10 days at a standard dosing regimen is the preferred treatment for an initial episode of CDI; this recommendation is conditional, with a moderate certainty of evidence. Oral vancomycin for 10 days at a standard dosing regimen is an acceptable alternative. […] The IDSA-SHEA guidelines suggest using fidaxomicin as a standard or extended-pulsed dosing regimen over vancomycin in patients with a first recurrence of CDI; this is a conditional recommendation with a low certainty of evidence. The guidelines also state that vancomycin (either standard dosing or a tapered and pulsed regimen) is an acceptable alternative.

• #72 Clostridioides (Clostridium) Difficile Colitis Treatment & Management: Approach Considerations, Pharmacologic Management, Fecal Microbiota Transplantation

  https://emedicine.medscape.com/article/186458-treatment

  In fulminant cases, combined therapy with IV metronidazole and vancomycin (PO or PR) is the treatment of choice. IV vancomycin is ineffective and should not be used for C difficile. […] FMT is a novel therapy that involves the transfer of stool from a healthy donor to a patient with CDI to reconstitute the normal colonic microbial flora. It is given after treating CDI with antibiotics. Studies have evaluated prevention of recurrence of CDI after FMT. […] Several studies have shown that FMT by colonoscopy or enema was an effective approach for patients with recurrent CDI, with clinical success rates of up to 95%. […] In November 2022, the FDA approved microbiota via rectal administration (Rebyota) for prevention of recurrence of CDI in adults following antibiotic treatment for CD recurrence.

• #73 Consensus on the prevention, diagnosis, and treatment of Clostridium difficile infection | Revista de Gastroenterología de México

  https://www.revistagastroenterologiamexico.org/en-consensus-on-prevention-diagnosis-treatment-articulo-S2255534X19300295

  In recent decades, Clostridium difficile infection (CDI) has become a worldwide health problem. […] Among them, it was recognized that CDI should be suspected in subjects with diarrhea that have a history of antibiotic and/or immunosuppressant use, but that it can also be a community-acquired infection. A 2-step diagnostic algorithm was proposed, in which a highly sensitive test, such as glutamate dehydrogenase (GDH), is first utilized, and if positive, confirmed by the detection of toxins through immunoassay or nucleic acid detection tests. […] In mild-moderate CDI, oral vancomycin is the medication of choice, and metronidazole is recommended as an alternative treatment. In addition, fecal microbiota transplantation was recognized as an efficacious option in patients with recurrence or in the more severe cases of infection, and surgery should be reserved for patients with severe colitis (toxic megacolon), in whom all medical treatment has failed.

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