New Treatment Guidelines for Clostridium Difficile

The Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) have released updated guidelines for Clostridium difficile infections. Some recommendations seem to mirror previous guideline recommendations. These include discontinuing therapy with the inciting antibitoic as soon as possible, use of a private room for patients in hospitals and other institutions, and the importance of personal protective equipment such as gloves and gowns when caring for patients with C difficile. However, the updated guidelines do make some interesting and very different recommendations from previous guidelines.

Perhaps one of the biggest changes in the recommendation is the initial C difficile infection (CDI) treatment. For the first time in almost 3 decades, metronidazole is no longer recommended as first-line therapy in adults. Instead, oral vancomycin (125 mg, 4 times a day) or fidaxomicin (200 mg twice daily) are recommended for 10 days in both nonsevere and severe CDI. The change in treatment recommendation was made based on evidence to support that use of vancomycin or fidaxomicin provide patients with the highest liklihood of sustained symptom resolution one month after treatment. In patients with nonseverse cases of CDI, metronidazole is still recommended when patients are unable to obtain or be treated with vancomycin or fidaxomicin. In patients with severe, complicated CDI with shock, hypotension, ileus, or megacolon, vancomycin 500 mg 4 times a day is recomended with parenteral metronidazole. Patients with ileus can be administered vancomycin via retension enema.

Metronidazole is not recommended for recurrent CDI infections. If it was used initialy, patients should receive a 10-day course of oral vancomycin. However, this standard course of oral vancomycin should also not be prescribed for recurrent infections if it has been tried previously. If the standard regimen of oral vancomycin was used initially, the guidelines recommend 1 of 2 options for the first recurrence of CDI. One option is to utilize fidaxomicin. This involves using a prolonged tapered and pulsed vancomycin regimen that is administered over approximately 6-12 weeks. Recommendations for additional recurrances also include fidaxomicin and pulsed/tappered oral vancomycin. Patients may also be managed with 10 days of vancomycin followed by 20 days of rifaximin or a fecal transplant.

The guidelines do not make a recommendation regarding the role of probiotics due to what they cite as a lack of evidence.

The guidelines also make specific recommendations for CDI involving testing, isolation, hand hygiene, and antibiotic stewardship.

Because the recommendations in these guidelines differ notably from previous versions, pharmacists can play an important role in ensuring the optimal treatment approach for patients with CDI, particularly when it appears that a patient may be being treated for CDI according to outdated guidelines.

References

1. McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Disease. 2018. Available http://www.idsociety.org/Guidelines/Patient_Care/IDSA_Practice_Guidelines/Infections_By_Organ_System-81567/Gastrointestinal/Clostridium_difficile/