Regardless of disease severity, one of the strongest recommendations is to discontinue any inciting antibiotics. This point, along with the recommendation to avoid anti-peristaltic agents, has also been emphasized in prior guidelines. Additionally, the authors note that although providers commonly prescribe treatment for 14 days, there is no evidence to suggest that a 14-day treatment course is more efficacious than a 10-day course for either metronidazole or vancomycin.
Management of severe and complicated CDI. Severe and complicated disease refers to CDI in patients meeting at least one of the following criteria: admission to the ICU, hypotension, fever ≥38.5°C, ileus or significant abdominal distention, mental status changes, WBC ≥35,000 or <2,000 cells/mm3, serum lactate >2.2 mmol/L, or end-stage organ failure. This definition is more specific than the SHEA-IDSA guidelines, which categorize severe and complicated disease as situations where shock, ileus, or megacolon are present. The recommended treatment is combined therapy with oral vancomycin 125 mg four times daily, plus intravenous metronidazole 500 mg three times daily. Surgical consultation should be obtained in all patients with complicated CDI. Colectomy should be considered in patients with evidence of severe sepsis, leukocytosis of ≥50,000, lactate ≥5 mmol/L, and failure to improve with medical therapy.
Patients with ileus or history of bowel surgery in whom oral antibiotics may not reach the colon should have vancomycin per rectum (enema of 500 mg in 100 mL to 500 mL of normal saline every six hours) added to the above treatments, regardless of disease severity.
Management of recurrent CDI. Consistent with previously published guidelines, the ACG recommends that the first recurrence of CDI be treated with the same regimen that was used for the initial episode. Second recurrences should be treated with a pulsed oral vancomycin regimen. Data are lacking regarding specific taper regimens, but the ACG suggests vancomycin 125 mg four times daily for 10 days, followed by a 125 mg dose every three days for 10 doses. For additional recurrences, fecal microbiota transplant may be considered. Reports suggest that this practice is safe and effective, but data from randomized controlled trials are lacking.
There is limited evidence to support the use of other antibiotics (e.g. rifampin, rifamixin), probiotics, or immunotherapy in the prevention of recurrent CDI.
Management of CDI in patients with comorbid conditions. A unique feature of the 2013 ACG guidelines is the incorporation of recommendations for patient groups who are at elevated risk for developing CDI or associated complications. Patients with inflammatory bowel disease (IBD) are one such group, as they often have underlying colonic inflammation and ongoing immunosuppression. The authors recommend that patients presenting with IBD flares be tested for C. diff. Other immunocompromised populations, including patients with malignancy, exposure to chemotherapy or corticosteroids, organ transplantation, and cirrhosis, should also be tested for CDI when presenting with diarrheal illness. Similarly, pregnant and peripartum women are considered high-risk and should undergo early testing and prompt initiation of treatment for CDI in the setting of diarrhea.
Infection control and prevention. Like SHEA-IDSA, the ACG recommends a hospital-based infection control program, antibiotic stewardship, and strict use of contact precautions for patients with known or suspected CDI. Contact precautions should be continued at minimum for the duration of diarrhea. Patients should be placed in private rooms and disposable equipment should be used, when possible. Disinfection of environmental surfaces is critical, as the environment is a common source of nosocomial infection. Disinfectants should have an Environmental Protection Agency-registered C. diff sporicidal label claim or contain a minimum concentration of chlorine solution. Important: Hand-washing with soap and water is required, as alcohol-based antiseptics are not active against C. diff spores.