UPDATES
December 2019: Updated treatment algorithm categorization and dosing
October 2018: GVH created a C-difficile testing decision tree to reduce the incidence of inappropriate stool sampling, see below​
April 2018: IDSA updated its guidelines, and GVH's protocol below reflects those changes. Highlights include oral vancomycin now being the treatment of choice, oral metronidazole no longer being used in C. difficile infection of any severity, and IV metronidazole being reserved for combination therapy with vancomycin 500 mg PO for severe complicated cases, which are now referred to as "fulminant"​
TESTING
  • See new GVH decision tree below
  • Test only when patient has diarrhea (unformed stool), unless ileus due to C. difficile is suspected
  • Do not test asymptomatic patients or test for cure. Patients may test positive for up to 6 weeks following treatment of C. difficile.
  • Our institution has PCR testing- rapid, sensitive, specific
    • Not recommended to repeat test during the same episode of diarrhea.  It has been found to have limited value.

initial episode

If the antibiotic causing the C. diff infection cannot be stopped at the time C. diff diagnosis is made because the patient must continue treatment for a different infection, continue the C. diff treatment for 1 week after the final dose of the causative antibiotic. Change to vancomycin 250 mg PO QID if this is the case.
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RECURRENCE
  • 1st Recurrence
    • If metronidazole was used for the initial episode, give vancomycin 125 mg PO QID for 10 days
    • If vancomycin was used for the initial episode, give prolonged vancomycin PO taper or pulse regimen (125 mg PO QID for 10-14 days, BID for 7 days, daily for 7 days, and then every 2 to 3 days for 2-8 weeks)
 
  • 2nd or Subsequent Recurrence
    • Consult infectious disease for treatment. May require alternate methods for treatment.

RISK FACTORS
  • Advanced age (>64 years )
  • Duration of hospitalization
    • Risk increased with longer length of stay
  • Exposure to antimicrobial agents
    • Risk increased the longer the patient is on the antimicrobial agent
    • Risk increased when patient is on more than one antimicrobial agent
  • Cancer chemotherapy/immunosuppressed
  • Gastrointestinal surgery, manipulation of GI tract, tube feeding
  • Questionable- use of PPI and H2 blockers​

FACILITIES
  • Healthcare workers and visitors should wear gowns and gloves before entering a patient’s room with C. difficile.
  • Hand hygiene is extremely important.  Wash with soap and water before and after contact with infected patient. Alcohol based hand sanitizers are not recommended as the C. difficile spores  are resistant to killing by alcohol.
  • Keep patient in a private room under contact precautions
  • Contact precautions must be maintained for duration of the diarrhea
  • It is not recommend to test asymptomatic carriers or to treat those identified individuals for infection control purposes.
  • Use chlorine-containing cleaning agents or other sporicidal agents
 
ANTIBIOTICS
  • Minimize frequency, duration, and number of antibiotics whenever possible to prevent C. difficile.
  • If patient is on antibiotics when C. difficile is identified, try to deescalate the antibiotics or discontinue the inciting antibiotic totally when appropriate to help decrease chance of recurrence. If the antibiotic causing the C. diff infection cannot be stopped at the time C. diff diagnosis is made because the patient must continue treatment for a different infection, continue the C. diff treatment for 1 week after the final dose of the causative antibiotic. Change to vancomycin 250 mg PO QID if this is the case. Metronidazole levels in the feces of a patient who no longer has active colitis are sub –therapeutic.
  • Antibiotics that are not implicated in C. difficile as often are vancomycin, aminoglycosides, macrolides, sulfonamides, and tetracycline.
 
PROTON PUMP INHIBITORS
  • It is recommended that PPI’s be stopped on patients with C. difficile or a history of C. difficile if possible.
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REFERENCES​​​​​​​
  1. Cohen SH, Gerding DN, Johnson S, et al.  Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA).  Infection Control and Hospital Epidemiology 2010; 31: 431-455.
  2. Kelly CP. Clostridium difficile in adults: Treatment.  In UpToDate, Calderwood SB (Ed), UpToDate, Waltham (MA): UpToDate, Inc.; 2017 [cited 2017 May 16]. Available from https://www.uptodate.com/contents/clostridium-difficile-in-adults-treatment?source=search_result&search=c%20difficile&selectedTitle=1~150.