Category Archives: C. diff. for Healthcare Providers

American College of Gastroenterology Issued New Guidelines On Management Of Clostridioides difficile (C. diff., C. difficile, CDI)

The American College of Gastroenterology has issued new guidelines on the management of Clostridioides difficile infection (CDI), with recommendations reflecting developments from the availability of biologics to the growing use of fecal microbiota transplantation (FMT).

“These guidelines are a step forward in our understanding of C. difficile,” commented Sahil Khanna, MBBS, MS, a professor of medicine at Mayo Clinic in Rochester, Minn., who was not involved in the guideline development.

“For the practicing provider, there are some big changes in the treatment and testing of the disease,” Dr. Khanna said. For example, although the 2013 ACG guidelines on the topic recommended metronidazole or vancomycin for treatment of a first mild to moderate episode of CDI, he said, the new guidelines now suggest vancomycin or fidaxomicin (Dificid, Merck) for a first episode of non-fulminant CDI. Metronidazole now is suggested only as treatment for initial non-severe CDI in very low-risk patients.

“Metronidazole has already been on the decline in clinical use, and I think these guidelines will lead to further reduction of its use,” Dr. Khanna said.

A notable update in the new guidelines is a recommendation that bezlotoxumab (Zinplava, Merck) be considered for the prevention of CDI recurrence in patients at high risk for recurrence, he said. “This is the first time bezlotoxumab has made it into a major society guideline for the gastroenterology and infectious disease community, and I think it will help get the drug covered more often by payors and make it available more widely to the practicing clinician.”

ACG 2021
Annual Scientific Meeting & Postgraduate Course

The Premier GI Clinical Meeting
& Postgraduate Course

October 22-27, 2021 • Mandalay Bay

Another update that reflects the evolving body of evidence that has emerged over the past several years is a strong recommendation that FMT be considered for use after two CDI recurrences, or in patients with severe and fulminant CDI refractory to antibiotic therapy, particularly when they are poor surgical candidates, Dr. Khanna said. “The previous recommendation in 2013 was to consider FMT, but the body of research has grown to demonstrate its efficacy,” he said.

The guideline authors recommend that FMT be repeated for patients experiencing a recurrence of CDI within eight weeks of an initial FMT. In addition, for patients with recurrent CDI who are not candidates for FMT, have relapsed after FMT, or require ongoing or frequent courses of antibiotics, the guidelines suggest using long-term suppressive oral vancomycin.

For patients with a first recurrence of CDI, the guidelines suggest use of tapering or pulsed-dose vancomycin or fidaxomicin if patients were previously administered vancomycin or metronidazole.

The guidelines recommend testing only of patients with symptoms suggestive of active CDI and use of a highly sensitive and specific CDI testing algorithm to help distinguish between colonization and active infection.

According to the guidelines, severe CDI is diagnosed if the white blood cell count is 15,000 cells/mm3 or higher or serum creatinine is greater than 1.5 mg/dL, and fulminant CDI should be diagnosed if the patient has hypotension, shock, ileus or megacolon in the presence of typical CDI symptoms.

For patients with fulminant CDI, the guideline authors urge adequate volume resuscitation and oral vancomycin for the first 48 to 72 hours, with the possible addition of parenteral metronidazole, and use of vancomycin enemas for patients with an ileus.

The panel also recommends against discontinuing antisecretory therapy when it is indicated in patients with CDI. They also include a recommendation against the use of probiotics to prevent CDI or recurrent CDI.

There are several recommendations specifically targeted to the inflammatory bowel disease population, including CDI testing of IBD patients presenting with an acute flare and diarrhea. Other population-specific recommendations target patients who are pregnant, lactating or immunocompromised.


ACG 2021
Annual Scientific Meeting & Postgraduate Course

The Premier GI Clinical Meeting
& Postgraduate Course

October 22-27, 2021 • Mandalay Bay


Changes In Electronic Health Records (EHR) To Guide Clinicians In C. diff. Diagnostic Stewardship – To Pause Testing When Not Clinically Indicated

An intervention that required administrative approval of all Clostridioides difficile testing after

hospital day 3 out-performed electronic health record-based support in reducing

C. difficile testing, according to a study.

“We made a series of changes in the electronic health records (EHRs) that we hoped would discourage clinicians from ordering C. difficile tests when testing was not clinically indicated, such as when patients with diarrhea had a more likely explanation such as recent laxative use, or when testing was ordered on patients who were not having diarrhea or other symptoms of C. difficile infection at all,” Lewis said. “In addition, one hospital in our system independently implemented a physician ‘gatekeeper’ to approve all C. difficile test orders for admitted patients.”

“We performed this work as part of a larger quality improvement initiative with the goal of improving the accuracy of diagnosis of C. difficile infection in order to improve quality of care for patients and decrease our health system’s publicly reported rates of C. difficile,” Sarah S. Lewis, MD, MPH, associate professor of medicine in the division of infectious diseases at Duke University Medical Center, told Healio.

“We made a series of changes in the electronic health records (EHRs) that we hoped would discourage clinicians from ordering C. difficile tests when testing was not clinically indicated, such as when patients with diarrhea had a more likely explanation such as recent laxative use, or when testing was ordered on patients who were not having diarrhea or other symptoms of
C. difficile infection at all,” Lewis said. “In addition, one hospital in our system independently implemented a physician ‘gatekeeper’ to approve all C. difficile test orders for admitted patients.”

Lewis and colleagues tested the three EHR-based interventions at three hospitals. The first intervention, initiated in January 2018, alerted clinicians ordering a test if laxatives were administered within 24 hours. The second, initiated in October 2018, canceled test orders after 24 hours. Implemented in July 2019, he third intervention involved “contextual rule-driven order questions” that required justification when laxatives were administered or there was a lack of EHR documentation of diarrhea. In February 2019, one of the three hospitals then implemented the “gatekeeper intervention” requiring approval for all C. difficile tests after 3 days in the hospital.

Sarah S. Lewis

Lewis and colleagues estimated the impact of the interventions on C. difficile testing and hospital-onset C. difficile infection (HO-CDI) using an interrupted time-series analysis. They found that C. difficile testing was already declining in the preintervention period (annual change in incidence rate [IR] = 0.79; 95% CI, 0.72-0.87) and did not decrease further with the EHR interventions.

The study demonstrated, however, that the laxative alert was temporally associated with a trend reduction in HO-CDI (annual change in IR from baseline = 0.85; 95% CI, 0.75-0.96) at two hospitals. Meanwhile, the gatekeeper intervention at the third hospital was associated with level (incidence rate ratio [IRR[ = 0.5; 95% CI, 0.42-0.6) and trend reductions in C. difficile testing (annual change in IR = 0.91; 95% CI, 0.85-0.98) and level (IRR = 0.42; 95% CI, 0.22-0.81) and trend reductions in HO-CDI (annual change in IR = 0.68; 95% CI, 0.5–0.92) relative to the baseline period, the researchers reported.

“Diagnostic stewardship, or the appropriate utilization of diagnostic tests, is important for improving quality of care. Electronic decision support in the form of alerts or background logic to reinforce the desired provider behavior is attractive because it is relatively low resource, easy to implement, and can be programmed in a way that is relatively unobtrusive to the clinical workflow,” Lewis said. “However, as we and others have seen, decision support often needs to be coupled with both provider education and some form of administrative restriction to achieve desired goals.”

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C. diff. Spores and More Live Broadcast Enters Season VI

Welcome to Season VI on 

C. diff. Spores and More

Live Broadcast, sponsored

by Clorox Healthcare.


With over 260 archived episodes ~ Listen At Your Leisure

It’s a new year with an entirely new line up of guests eager to share their C. difficile research, infection prevention methods, clinical trials in progress, the updates in the C. diff. community, and much more.





In March the post-Patient and Family Symposium presentations will broadcast, in the event you weren’t able to attend the live-online event hosted on January 15th. The first annual Patient and Family Symposium was sponsored by Seres Therapeutics

Do you have a specific topic of interest or would like to learn more about a specific product or procedure?  Send an email to and share your suggestions and interests.

“None of us can do this alone ~ All of us can do this together.”

Join us every Tuesday at 1:00 p.m. EST for the Live Broadcast


A Team, Led by Travis J. Carlson, Department of Clinical Sciences, High Point University Fred Wilson School of Pharmacy, Define Kidney Injuries as a CDI Disease Severity Marker

Travis Carlson, PharmD

A recent update (Oct. 2020)  of the guidelines for Clostridioides difficile infections (CDI) might allow clinicians to accurately predict viral severity in kidney disease patients.

In 2017, the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) revised their C. diff infection severity classification criteria to include an absolute serum creatinine (SCr) value above the threshold of at least 1.5 mg/dL as opposed to a relative increase from baseline of at least 1.5 times the premorbid level.

A team, led by Travis J. Carlson, Department of Clinical Sciences, High Point University Fred Wilson School of Pharmacy, sought to best define kidney injuries as a CDI disease severity marker to make it easier to assess severe outcomes linked to CDI.

In the multicenter, cohort study, the investigators assessed adult hospitalized patients with a C. diff infection for the presence of an acute kidney injury (AKI), chronic kidney disease (CKD), and CDI severity using the 2010 and 2017 IDSA/SHEACDI guidelines.

The investigators sought primary outcomes of all-cause inpatient mortality.

In the final analysis, the investigators examined 770 C. diff infection episodes from a total of 705 patients aged 65±17 years (female, 54%; CKD, 36.5%; AKI, 29.6%).

In addition, 82 episodes (10.6%) showed discordant severity classification results because of the inclusion of more patients with preexisting chronic kidney disease in the severe disease category using an absolute SCr threshold criterion.

The absolute SCr criterion better correlated with all-cause mortality (OR, 4.04; 95% CI, 1.76-9.28; P = 0.001) than the relative increase in SCr (OR, 1.34; 95% CI, 0.62-2.89; = 0.46).

The investigators found this corresponded with an increased likelihood of the 2017 CDI severity classification criteria to predict mortality (OR, 5.33; 95% CI, 1.81-15.72; = 0.002) compared to the 2010 criteria ( OR, 2.71; 95% CI, 1.16-6.32; = 0.02).

“Our findings support the 2017 IDSA/SHEA CDI severity classification criteria of a single pre-treatment SCr in future CDI guideline updates,” the authors wrote.

New data shows positive trends regarding C. diff infections and hospitalization within the last 10 years.

A team, led by Alice Y. Guh, MPH, identified cases of C. diff infections in stool specimens positive for C. diff in an individual at least 1-year-old with no positive test in the previous 8 weeks in 10 US sites.

Overall, they identified 15,461 cases in 2011—10,177 healthcare-associated cases and 5284 community-associated cases. In 2017, they identified 15,512 cases—7973 healthcare-associated cases and 7539 community-associated cases.

The estimated national burden of infections was 476,400 (95% CI, 419,900-532,900) in 2011 and 462,100 cases (95% CI, 428,600-495,600) in 2017.

After accounting for NAAT use, the adjusted estimate of the total burden of C. diff infection decreased by 24% from 2011 through 2017 (95% CI, 6-36).

The study, “Assessment of Kidney Injury as a Severity Criteria for Clostridioides difficile Infection,” was published online in Open Forum Infectious Diseases

Clorox Healthcare Spore* Defense Cleaner Disinfectant – First Sporicidal Solution For Clorox Total 360 System

In The News

Clorox Healthcare Spore* Defense Cleaner Disinfectant is a ready-to-use, low odor bleach that kills C. difficile in five minutes.

Clorox Healthcare has announced the first sporicidal solution, Clorox Healthcare Spore Defense Cleaner Disinfectant, available through the Clorox® Total 360® System, an electrostatic sprayer that combines proven electrostatic technology with trusted Clorox® solutions to easily provide superior coverage in even the hardest-to-reach places.

Clorox Healthcare Spore Defense Cleaner Disinfectant is a low fragrance bleach that kills C. diff in five minutes in addition to 42 other pathogens and can be used in sensitive patient settings. In turn, this new product provides healthcare professionals a facility-wide solution by ensuring C. diff spores, among other pathogens, are killed on hard, non-porous surfaces in patient rooms, in operating rooms, and on transport equipment often missed during manual cleaning.

Disinfecting surfaces in hospitals is challenging and time-consuming work. Research suggests only 50 percent of surfaces in patient rooms and operating rooms are effectively disinfected.¹ Proper disinfection of portable and shared medical equipment is also an important component of infection prevention as this equipment frequently becomes contaminated with healthcare-associated pathogens. In addition, such equipment often has irregular and difficult-to-clean surfaces resulting in suboptimal manual cleaning and disinfection.

In fact, a study conducted by Curtis Donskey, MD, Infectious Disease Specialist, Louis Stokes Cleveland Veterans Affairs Medical Center, found medical equipment was not disinfected after use 90 percent of the time. Sampling also showed that 27.5 percent of mobile equipment had one or more pathogens on them. These results demonstrate that mobile equipment is frequently used, infrequently cleaned, and can serve as a vector for the dissemination of pathogens.²

“Through this study, it became abundantly clear that healthcare facilities needed an efficient solution to help prevent the transmission of healthcare-associated pathogens from portable medical equipment,” said Lynda Lurie, Director of Marketing, Clorox Professional Products Company. “Clorox Healthcare Spore Defense Cleaner Disinfectant through the Clorox® Total 360® System makes a challenging, but imperative task easier for end-users while also providing complete coverage. Healthcare facilities can finally rest assured knowing they covered the germ hot spots often missed through manual cleaning.”

The Clorox® Total 360® electrostatic sprayer works by charging and atomizing Clorox Healthcare Spore Defense Cleaner Disinfectant, delivering a powerful flow of charged particles that are attracted to surfaces with a force stronger than gravity. This allows the product to reach and uniformly coat hard, non-porous surfaces including hard-to-reach areas that manual cleaning can often miss.

Clorox Healthcare Spore Defense Cleaner Disinfectant has been extensively tested for efficacy, residue, and worker protection. This solution was developed to be safe to use through the Clorox® Total 360® System and ensure the combined products effectively enhance surface coverage while reducing the time it takes to treat healthcare surfaces.


Dr. Donskey examined the efficiency of the sporicidal solution against C. diff reduction on healthcare surfaces in the real-world including wheelchairs, portable equipment, and waiting rooms. Findings showed the Clorox® Total 360®  System with Spore Defense was just as effective as bleach wipes in reducing C. diff spores inoculated on wheelchairs but could be applied in one-fourth of the time, providing healthcare facilities with a rapid and effective means to reduce spore contamination on surfaces like never before.³

“When it comes to the cleaning and disinfection of shared and portable medical equipment such as wheelchairs and gurneys, thoroughness of cleaning is often suboptimal and application can be challenging and time-consuming, especially when surfaces are irregular,” said Donskey. “This is what makes the development of this sporicidal solution and its ability to be used with electrostatic technology a substantial innovation – it provides a solution for healthcare facilities that wasn’t previously possible.”

With broad surface compatibility, low residue profile, 43 pathogen kill claims, and low odor, Clorox Healthcare Spore Defense Cleaner Disinfectant is easily implementable for facility-wide use. Spore Defense also meets the EPA Emerging Viral Pathogen designation for use against SARS-CoV-2, the virus that causes COVID-19.

To learn more about the Donskey studies, please view the white paper/case study here. To learn more about Clorox Healthcare Spore Defense Cleaner Disinfectant and the Clorox® Total 360® System, please visit

¹ Bhalla A., Pultz N.J., Gries D.M. et al. “Acquisition of Nosocomial Pathogens on Hands After Contact With Environmental Surfaces Near Hospitalized Patients.” Infection Control Hospital Epidemiology. 2004 Feb;25(2): 164–7
² Donskey, C., Study Update: Cleveland VAMC showcases Clorox Total 360 Spore Defense results at IDWeek 2019. Cloroxpro. Accessed April 3, 2020.
³ Donskey, C., Evaluation of a novel sporicidal spray disinfectant for decontamination of surfaces in healthcare. CloroxPro. Accessed April 3, 2020. 
∗ Clostridium difficile spores only