American Society of Colon and Rectal Surgeons (ASCRS) June 2021 Clinical Practice Guidelines: Management of a CDI

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Clostridioides difficile Infection

Poylin, Vitaliy M.D.1; Hawkins, Alexander T. M.D., M.P.H.2; Bhama, Anuradha R. M.D.3; Boutros, Marylise M.D.4; Lightner, Amy L. M.D.5; Khanna, Sahil M.B.B.S., M.S.6; Paquette, Ian M. M.D.7; Feingold, Daniel L. M.D.8; Prepared by the Clinical Practice Guidelines Committee of The American Society of Colon and Rectal Surgeons

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Diseases of the Colon & Rectum: June 2021 – Volume 64 – Issue 6 – p 650-668
doi: 10.1097/DCR.0000000000002047

The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. Although not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines.

These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician considering all the circumstances presented by the individual patient.


Clostridioides difficile, formerly known as Clostridium difficile, is an anaerobic, gram-positive, bacillus bacterium that can be a normal inhabitant of the human colon and is most commonly transmitted via a fecal-oral route.1 Alterations in the bacterial component of the microbiota, most often due to the use of antibiotics, can lead to ecological changes that select for both population growth of C difficile as well as the induction of pathogenic behavior.2,3 Although the number of patients with C difficile infection (CDI) in the United States appears relatively stable over the past decade (estimated 476,400 cases in 2011 associated with 29,000 deaths and 462,100 cases in 2017 associated with an estimated 20,500 deaths), the prevalence of the disease remains high.3–5 Although the bacterium is present in the stool of approximately 3% of healthy adults, up to 50% of those exposed to an inpatient facility may be asymptomatic carriers.5–8 Higher rates of CDI have been reported in patients after exposure to a prolonged duration of antibiotics including perioperative antibiotics and in patients with underlying comorbid conditions such as IBD or immunosuppression.9–15

Clinical manifestations of C difficile can range from an asymptomatic carrier state to mild CDI to severe, fulminant, life-threatening infection. Although descriptions of presentation and severity of disease vary in the literature, commonly used definitions are included in Table 1.16–19C difficile infection most commonly involves the colon, where it can manifest with pseudomembranes covering the colonic mucosa (“pseudomembranous colitis”). In rare circumstances, CDI may also involve the small bowel.20,21 In the early 2000s, predominantly in North America, but also in Europe, there was an increased incidence of more severe CDI due to the emergence of certain bacterial strains (ie, ribotypes) like the BI/NAP1/027/toxinotype III strain, which is associated with a life-threatening infection.22–25 Although rates of infection with this “hypervirulent” strain recently decreased in North America, rates remain significant globally.26,27

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