Updated guidelines for C. diff infection address fecal transplant, laboratory testing

The guidelines recommend laboratory testing for C. diff only in patients with new-onset, unexplained diarrhea, defined as at least three unformed stools in 24 hours, among other guidance.


Patients with two or more recurrences of Clostridium difficile infection who have not responded to traditional antibiotic treatment should undergo fecal microbiota transplantation (FMT), among other recommendations in recently updated guidelines from the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).

The guidelines were developed by experts in epidemiology, diagnosis, infection control, and clinical management of adult and pediatric patients and update the 2010 IDSA/SHEA guidelines on this topic. Areas covered include epidemiology, diagnosis, infection prevention and control, and treatment.

The guidelines recommend laboratory testing for C. diff only in patients with new-onset, unexplained diarrhea, defined as at least three unformed stools in 24 hours. However, when there are no preagreed institutional criteria that limit testing to such patients, the guidelines recommend that a C. diff common antigen test and a stool toxin test, such as an immunoassay, be used as part of a two- or three-step test process.

The updated guidelines strongly recommend that frequency and duration of high-risk antibiotic therapy and the number of agents prescribed be minimized. The guidelines also include a good practice recommendation that antibiotic stewardship should be implemented and strongly recommend considering restriction of fluoroquinolones, clindamycin, and cephalosporins, except for surgical antibiotic prophylaxis.

The guidelines strongly recommend FMT for patients who have two or more C. diff recurrences and in whom traditional antibiotic treatment has not been successful. FMT is a relatively new treatment and was not available when the 2010 guidelines were written, the guideline authors noted. Although FMT is not approved by the FDA, the agency has issued guidance on its use in resistant C. diff infection, the IDSA noted in a press release.

Other new guidance includes a strong recommendation for initial treatment with vancomycin or fidaxomicin, even in mild cases of C. diff, rather than metronidazole, which was recommended as first-line therapy in the 2010 guidelines.

The guidelines make no recommendation for the use of probiotics, noting that currently available data are insufficient. In addition, therapy with bezlotoxumab and testing with multiplex polymerase reaction platforms are not covered, since both became available after the guidelines were completed. The guideline authors noted that these two areas would be addressed in future updates.

The guidelines were published Feb. 15 by Clinical Infectious Diseases and are available online.