ACG updates clinical guidelines on prevention, diagnosis, treatment of C. difficile infection

While the American College of Gastroenterology (ACG) included new recommendations for using fecal microbiota transplantation in recurrent Clostridioides difficile infection, it recommended against the use of probiotics for both primary and secondary prevention.


A lot has happened in the field since the American College of Gastroenterology (ACG) last published guidelines on managing Clostridium difficile infection (CDI) in 2013.

In 2016, the organism was assigned to a new genus and is now called Clostridioides difficile. Other developments include new therapeutic options for treatment and prevention of recurrence, as well as increasing evidence to support fecal microbiota transplantation (FMT) in recurrent and severe infection, according to the ACG's updated clinical guidelines on prevention, diagnosis, and treatment of CDI, which were published May 18 by the American Journal of Gastroenterology.

Among other recommendations, the guidelines:

  • recommend against the use of probiotics for both primary prevention of CDI in patients being treated with antibiotics (conditional recommendation, moderate quality of evidence) and prevention of CDI recurrence (strong recommendation, very low quality of evidence). The 2013 guidelines had noted there was limited evidence for the use of adjunct probiotics to decrease recurrences in patients with recurrent CDI (moderate recommendation, moderate quality of evidence).
  • recommend treating an initial episode of nonsevere CDI with oral vancomycin (125 mg four times daily for 10 days; strong recommendation, low quality of evidence), oral fidaxomicin (200 mg twice daily for 10 days; strong recommendation, moderate quality of evidence), or oral metronidazole in low-risk patients (500 mg three times daily for 10 days; strong recommendation, moderate quality of evidence). The previous guidelines recommended metronidazole for patients with mild to moderate CDI, with nonresponse to therapy prompting consideration of a change to vancomycin (fidaxomicin was FDA-approved for the treatment of CDI in 2011).
  • recommend initially treating severe CDI with vancomycin (125 mg four times daily for 10 days; strong recommendation, low quality of evidence) or fidaxomicin (200 mg twice daily for 10 days; conditional recommendation, very low quality of evidence). The 2013 guidelines included a conditional recommendation to treat severe CDI with vancomycin.
  • recommend treatment with FMT to prevent further recurrences in patients experiencing their second or further recurrence of CDI (strong recommendation, moderate quality of evidence). The previous guidelines included a conditional recommendation to consider FMT if there is a third recurrence after a pulsed vancomycin regimen.
  • suggest considering FMT for patients with severe and fulminant CDI refractory to antibiotic therapy, particularly those who are deemed poor surgical candidates (strong recommendation, low quality of evidence).
  • recommend that FMT be delivered through colonoscopy (strong recommendation, moderate quality of evidence) or capsules (strong recommendation, moderate quality of evidence) for treatment of recurrent CDI and suggests delivery by enema if other methods are unavailable (conditional recommendation, low quality of evidence).

While FMT has emerged as an effective treatment, questions remain about best methods of delivery, optimal donor screening, and long-term safety, the authors of the guidelines noted. “Defined microbiota consortia may enable a more targeted approach to treatment of the underlying dysbiosis that drives CDI, and formulations of microbiota may soon gain regulatory approval,” they wrote. “If cost-effective and safe, these products may ultimately be used earlier in the clinical course, even after a first infection.”

Overall, antibiotic stewardship programs in hospital settings have been effective at reducing CDI incidence, but community spread is a growing problem that requires prevention efforts, the authors said. “CDI will remain a common and challenging clinical problem. … Understanding around the pathophysiology of the infection, including the relative roles of the gut microbiota and host immune factors, has increased, and further research may identify new targets for prevention and treatment,” they concluded.

The ACG also published clinical guidelines on the diagnosis and management of idiosyncratic drug-induced liver injury (an update of the 2014 guideline) and management of patients with upper GI and ulcer bleeding (an update of the 2012 guideline) in the May issue of the American Journal of Gastroenterology.