Tag Archives: What are the treatment options for C. difficile?

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.”

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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