Treatment of Clostridioides difficile Infection

GUIDELINE TITLE ACG Clinical Guidelines: Prevention,
Diagnosis, and Treatment of Clostridioides difficile Infections
RELEASE DATE May 18, 2021
PRIOR VERSION 2013
DEVELOPER American College of Gastroenterology (ACG)
FUNDING SOURCE ACG
TARGET POPULATION Adults with suspected or diagnosed
Clostridioides difficile infection (CDI)
MAJOR RECOMMENDATIONS
• Initial CDI should be treated with vancomycin or fidaxomicin
(strong recommendation; moderate-quality evidence).
Metronidazole may be considered in low-risk patients
with nonsevere infection (strong recommendation;
moderate-quality evidence).
• Fulminant CDI should be treated with high-dose
vancomycin (strong recommendation; very low-quality
evidence). Combination therapy with parenteral
metronidazole can be considered (conditional
recommendation; very low-quality evidence). If ileus is
present, vancomycin enemas are recommended
(conditional recommendation; very low-quality evidence).
Severe or fulminant CDI refractory to antibiotic therapy
may be treated with fecal microbiota transplantation (FMT)
(strong recommendation; low-quality evidence).
• A first CDI recurrence is treated with tapered-pulsed
vancomycin if vancomycin, fidaxomicin, or metronidazole
was used initially (strong recommendation; very
low-quality evidence) or with fidaxomicin if vancomycin or
metronidazole was used initially (strong recommendation;
moderate-quality evidence). Second or further CDI
recurrences are treated with antibiotics followed by FMT
(strong recommendation; moderate-quality evidence),
which may be repeated for recurrences within 8 weeks
(conditional recommendation; very low-quality evidence).
• Bezlotoxumab is recommended for high-risk patients for
recurrence prevention (conditi