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June 24, 2021
Clostridioides difficile Infection: Updated Recommendations
David J. Bjorkman, MD, MSPH (HSA), SM (Epid.), reviewing Kelly CR et al. Am J Gastroenterol 2021 Jun
Diagnosis and treatment are discussed, with substantial detail on fecal microbiota transplantation.
Sponsoring Organization: American College of Gastroenterology
Background
This clinically oriented document is meant to complement the Infectious Diseases Society of America's 2018 guideline on Clostridioides difficile infections (NEJM JW Infect Dis May 2018 and Clin Infect Dis 2018; 66:e1). The authors rate each recommendation as strong or conditional, and they grade the quality of supporting evidence as high, moderate, or low.
Selected Recommendations
A two-step diagnostic testing algorithm is favored: Start with a sensitive test for C. difficile infection (CDI), and when results are positive, perform specific testing for toxin.
Oral vancomycin or fidaxomicin generally is favored for treating patients with nonsevere CDI, but metronidazole is acceptable for low-risk patients — especially when cost is a factor.
Patients with severe CDI should be treated with either oral vancomycin or fidaxomicin (but not metronidazole). Severe disease is defined as having a leukocytosis >15,000 white blood cells/mm3 or a creatinine level of >1.5 mg/dL.
Fulminant CDI (defined as severe CDI plus hypotension, shock, ileus, or megacolon) should be managed with fluid resuscitation and high-dose oral vancomycin; addition of parenteral metronidazole and vancomycin enemas (for patients with ileus) can be considered.
Fecal microbiota transplantation (FMT) should be considered for refractory or severe CDI.
A first recurrence should be treated with tapering/pulsed-dose vancomycin or fidaxomicin if it was not the initial therapy. A patient experiencing a second or further recurrence of CDI should be treated with FMT, delivered via a colonoscope or capsules, with enemas used when colonoscopy or capsules are not available. Repeat FMT can be used to treat a recurrence within 8 weeks of initial FMT.
Patients with recurrent CDI who are not FMT candidates or have relapsed after FMT can be given long-term oral vancomycin prophylaxis to prevent recurrences. Oral vancomycin prophylaxis also can be considered when patients with recurrent CDI are given systemic antibiotics.
Additional recommendations are made for specific populations (those with inflammatory bowel disease, pregnancy, lactation, or immunocompromise) and for surgical intervention.
Probiotics should not be used for primary or secondary prevention of CDI.
Comment
The narrative discussions for each recommendation are well written, with balanced assessments of the strengths and limitations of supporting evidence. Overall, this document provides comprehensive updated guidance on managing CDI. Note: The Infectious Diseases Society of America currently is updating its guideline on C. difficile and will be recommending fidaxomicin as first-line treatment for a patient with an initial episode of C. difficile infection. However, the recommendation is “conditional” and acknowledges vancomycin as an acceptable alternative.
Updated recommendations
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Updated recommendations
If your illness was preceded by use of a medication, e.g., an antibiotic, please fill out an FDA Adverse Event Report at http://www.fda.gov/Safety/MedWatch/default.htm
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