ACG Releases New Guideline on C Diff

The American College of Gastroenterology (ACG) published new guidelines for the prevention, diagnosis, and treatment of Clostridioides difficile (CDI), noting the need to acknowledge developments since it last produced a guideline on CDI in 2013.

Those developments, the new guidelines state, “include the increased recognition of diagnostic challenges in the era of nucleic acid amplification–based testing, new therapeutic options for treatment and prevention of recurrence, and increasing evidence to support fecal microbiota transplantation (FMT) in recurrent and severe infection.”

The authors further noted the ACG guideline is “intended to be complementary to the recently updated Infectious Disease Society of America (IDSA) and Society of Healthcare Epidemiologists of America (SHEA) guidelines. The goal of the authors was to provide an evidence-based, clinically useful guideline for the diagnosis, management, and prevention of C. difficile infection (CDI).”

The guideline includes 8 key concept statements:

"Diagnosis

1. Only individuals with symptoms suggestive of active C. difficile infection (CDI) should be tested (3 or more unformed stools in 24 hr)

2. We recommend the following criteria, which are predictive of unfavorable outcomes, be used to classify severe CDI at the time of diagnosis: white blood cell ≥15,000 cells/mm3 or serum creatinine 1.5 mg/dL

3. We recommend defining fulminant infection as patients meeting criteria for severe CDI plus presence of hypotension or shock or ileus or megacolon.

Treatment

4. We suggest that for patients who require surgical intervention, either a total colectomy with an end ileostomy and a stapled rectal stump or a diverting loop ileostomy with colonic lavage and intraluminal vancomycin, be used depending on clinical circumstances, the patient’s estimated tolerance to surgery, and the surgeon’s best judgement.

Special populations

5. Immunosuppressive inflammatory bowel disease therapy should not be held during anti-CDI therapy in the setting of disease flare and escalation of therapy may be considered if there is no symptomatic improvement with treatment of CDI.

6. We recommend using vancomycin to treat pregnant and peripartum patients with CDI.

7. We recommend using vancomycin to treat breastfeeding patients with CDI.

8. We suggest vancomycin or fidaxomicin be used first line for treatment of CDI in patients who are immunocompromised."

The guideline includes several strong recommendations, including a recommendation against the use of probiotics to prevent recurrence of CDI; treatment of initial episodes of CDI with oral vancomycin, with dosages and extent of treatment depending on severity; use of oral metronidazole for initial nonsevere CDI in low-risk patients; and treatment of fulminant CDI with 500 mg of oral vancomycin every 6 hours daily for the first 48 to 72 hours.

“We suggest fecal microbiota transplantation (FMT) be considered for patients with severe and fulminant CDI refractory to antibiotic therapy, particularly when patients are deemed poor surgical candidates,” the authors continued. The guideline also recommends that patients who are experiencing “a second or further recurrence of CDI be treated with FMT to prevent further recurrences,” preferably delivered through colonoscopy or capsules.

For patients with inflammatory bowel disease, the authors recommend testing for CDI among those who present with an acute flare associated with diarrhea; treatment with vancomycin 125 mg p.o. 4 times a day for a minimum of 14 days; and consideration of FMT for patients with IBD who have recurrent CDI.

Read the full guideline here.

—Rebecca Mashaw

Reference:

Kelly CR, Fischer M, Allegretti JR et al. ACG clinical guidelines: prevention, diagnosis, and treatment of Clostridioides difficile infections. Am J Gastroenterol 2021;00:1–24. https://doi.org/10.14309/ajg.0000000000001278