Clostridium Difficile Colitis PDF

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Clostridium Difficile Colitis

Updated: Oct 10, 2018
Author: Faten N Aberra, MD, MSCE; Chief Editor: BS Anand, MD
Overview
Practice Essentials
Clostridium difficile colitis results from a disturbance of the normal bacterial flora of the colon, colonization by C difficile, and the
release of toxins that cause mucosal inflammation and damage. Antibiotic therapy is the key factor that alters the colonic flora. C
difficile infection (CDI) occurs primarily in hospitalized patients.
Signs and symptoms
Symptoms of C difficile colitis often include the following:
Mild to moderate watery diarrhea that is rarely bloody
Cramping abdominal pain
Anorexia
Malaise
Physical examination may reveal the following in patients with the disorder:
Fever: Especially in more severe cases
Dehydration
Lower abdominal tenderness
Rebound tenderness: Raises the possibility of colonic perforation and peritonitis
See Clinical Presentation for more detail.
Diagnosis
The diagnosis of C difficile colitis should be suspected in any patient with diarrhea who has received antibiotics within the
previous 3 months, has been recently hospitalized, and/or has an occurrence of diarrhea within 48 hours or more after
hospitalization.[1] In addition, C difficile can be a cause of diarrhea in community dwellers without previous hospitalization or
antibiotic exposure.[2]
Laboratory studies
Laboratory testing for evaluating patients with CDI includes the following:
Complete blood count: Leukocytosis may be present (the levels can be very high in severe infection)
Electrolyte levels, including serum creatinine: Dehydration, anasarca, and electrolyte imbalance may accompany severe
disease
Albumin levels: Hypoalbuminemia may accompany severe disease
Serum lactate level: Lactate levels are generally elevated (≥5 mmol/L) in severe disease
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Stool examination: Stool may be positive for blood in severe colitis, but grossly bloody stools are unusual; fecal
leukocytes are present in about half of cases
Stool assays for C difficile, from the most to the least sensitive, include the following:
Stool culture: The most sensitive test (sensitivity, 90-100%; specificity, 84-100%), but the results are slow and may lead
to a delay in the diagnosis if used alone
Glutamate dehydrogenase enzyme immunoassay (EIA): This is a very sensitive test (sensitivity, 85-100%; specificity, 87-
98%); it detects the presence of glutamate dehydrogenase produced by C difficile
Real-time polymerase chain reaction (PCR) assay: This test is an alternative gold standard to stool culture (sensitivity,
86%; specificity, 97%[3] ); it may be used to detect the C difficile gene toxin
Stool cytotoxin test: A positive test result is the demonstration of a cytopathic effect that is neutralized by a specific
antiserum (sensitivity, 70-100%; specificity, 90-100%)
EIA for detecting toxins A and B: This test is used in most laboratories (moderate sensitivity, 79-80%; excellent specificity,
98%)
Latex agglutination technique: Another means of detecting glutamate dehydrogenase; however, the sensitivity of this test
is poor (48-59%), although the specificity is 95-96%
Imaging studies and procedures
Abdominal computed tomography (CT) scanning is the imaging modality of choice for C difficile colitis when
pseudomembranous colitis (see the image below), complications of CDI, or other intra-abdominal pathology is suspected.[4] In
patients with sepsis due to suspected megacolon, abdominal radiography may be performed instead of CT scanning to establish
the presence of megacolon in a timely manner.
Computed tomography scan of pseudomembranous colitis.
Endoscopy is less sensitive for diagnosing C difficile than are stool assays. Endoscopy may demonstrate the presence of raised,
yellowish white, 2- to 10-mm plaques overlying an erythematous and edematous mucosa. These plaques are termed
pseudomembranes. Endoscopic findings may be normal in patients with mild disease or may demonstrate nonspecific colitis in
moderate cases.
See Workup for more detail.
Management
Treatment for CDI varies according to its severity. Interventions include the following:
Asymptomatic carriers: No treatment is necessary
Mild, antibiotic-associated diarrhea without fever, abdominal pain, or leukocytosis: Cessation of antibiotic(s) may be the
only treatment necessary
Mild to moderate diarrhea or colitis: Metronidazole (oral or intravenous) or vancomycin (oral) for 10 days
Severe or complicated disease: Vancomycin is considered to produce faster symptom resolution and fewer treatment
failures than metronidazole; in fulminant cases, combined therapy with intravenous metronidazole and oral (or per
rectum) vancomycin may be considered[5]
Relapse
Relapse occurs in 20-27% of patients. Once a patient has 1 relapse, the risk for a second relapse is 45%. Relapses should be
treated as follows:
First relapse: The choice of antibiotic should be based on the severity of C difficile diarrhea/colitis
Subsequent relapses: For every relapse after the first, vancomycin (prolonged taper/pulsed regimen) or fidaxomicin with
or without probiotics is recommended
Among various investigational therapies, fecal microbiota transplantation (fecal enemas or infusion of donor feces through a
nasoduodenal tube) has been reported to repopulate the colonic flora and treat recurrent CDI.[6, 7, 8]
See Treatment and Medication for more detail.
Background
Clostridium difficile is a gram-positive, anaerobic, spore-forming bacillus that is responsible for the development of antibiotic-
associated diarrhea and colitis. C difficile infection (CDI) commonly manifests as mild to moderate diarrhea, occasionally with
abdominal cramping. Pseudomembranes (adherent, yellowish white plaques on the intestinal mucosa) are occasionally
observed (see the images below). In rare cases, patients with C difficile infection can present with an acute abdomen and
fulminant, life-threatening colitis. (See Presentation.)
Endoscopic visualization of pseudomembranous colitis, a characteristic manifestation of full-blown <i>C difficile</i> colitis.
Classic pseudomembranes are visible as raised, yellow plaques ranging from 2 to 10 mm in diameter and scattered over the
colorectal mucosa. Courtesy of Gregory Ginsberg, MD, University of Pennsylvania.
Barium enema demonstrating the typical serrated appearance of the barium column (resulting from trapped barium between
the edematous mucosal folds and the plaquelike membranes of pseudomembranous colitis).
Approximately 20% of individuals who are hospitalized become colonized with C difficile during hospitalization, and more than
30% of these patients develop diarrhea. Thus, C difficile colitis is currently one of the most common nosocomial infections. (See
Pathophysiology and Etiology.)
The diagnosis of C difficile colitis should be suspected in any patient with diarrhea who has received antibiotics within the
previous 3 months, has been recently hospitalized, and/or has an occurrence of diarrhea 48 hours or more after hospitalization.
[1] However, more recent studies have shown that C difficile can be the cause of diarrhea in community dwellers without
previous hospitalization or antibiotic exposure[2] ; therefore, the diagnosis should be suspected in this population as well. (See
Presentation and Workup.)
Once infected with C difficile, the rate of disease recurrence is 20-40%, especially when first-line agents such as metronidazole
and vancomycin are not successful.[9] In patients with CDI who develop fulminant colitis, early surgical intervention is crucial.
Note that although intravenous immunoglobulin (IVIG) and tigecycline have been used in patients with severe refractory
disease, delaying surgery may lead to worse outcomes. (See Treatment and Medication.)[9] In addition, the use of tigecycline in
oncology patients with CDI has been reported with breakthrough CDIs in those who received it for non-CDI indications.[10]
Pathophysiology
C difficile colitis results from a disturbance of the normal bacterial flora of the colon, colonization with C difficile, and release of
toxins that cause mucosal inflammation and damage. Colonization occurs by the fecal-oral route. Hospitalized patients are the
primary targets of C difficile infection (CDI), although C difficile is present as a colonizer in 2-3% of healthy adults and in as
many as 70% of healthy infants.[11] (Treatment of asymptomatic carriers is not recommended.)
C difficile forms heat-resistant spores that can persist in the environment for several months to years. Outbreaks of C difficile
diarrhea may occur in hospitals and outpatient facilities where contamination with spores is prevalent. Although the normal gut
flora resists colonization and overgrowth with C difficile, the use of antibiotics, which alter and suppress the normal flora, allows
proliferation of C difficile, toxin production, and diarrhea.
Pathogenic strains of C difficile produce 2 distinct toxins. Toxin A is an enterotoxin, and toxin B is a cytotoxin; both are high–
molecular weight proteins capable of binding to specific receptors on the intestinal mucosal cells. Receptor-bound toxins gain
intracellular entry by catalyzing a specific alteration of Rho proteins—small glutamyl transpeptidase (GTP)–binding proteins that
assist in actin polymerization, cytoskeletal architecture, and cell movement. Both toxin A and toxin B appear to play a role in the
pathogenesis of C difficile colitis in humans.
More recently, rat studies suggest that C difficile toxin B induces senescence in enteric glial cells (ECGs); investigators
hypothesize that EGCs that survive toxin B and acquire senescence potentially cause the development of irritable bowel
syndrome and inflammatory bowel disease via persistent inflammation, transfer of senescence status, and stimulation of
preneoplastic cells.[94]
The NAP1 hypervirulent strain of C difficile is associated with the most serious sequelae of CDI, causing severe and fulminant
colitis that is characterized by leukocytosis, renal failure, and toxic megacolon.[12] The widespread use of fluoroquinolone
antibiotics may have played a role in the proliferation of the NAP1 strain. Once rising white blood cell count or hemodynamic
instability occurs and fulminant colitis is imminent, subtotal colectomy with end ileostomy is often necessary. Fecal
bacteriotherapy and immunotherapy are investigative treatment strategies that have potential for managing patients with severe
CDI.[12]
Etiology
C difficile colitis results from a disruption of the normal bacterial flora of the colon, colonization with C difficile, and release of
toxins that cause mucosal inflammation, mucosal damage, and diarrhea.
Risk factors
Antibiotic exposure
The primary risk factor for C difficile colitis is previous exposure to antibiotics; the most commonly implicated agents include the
cephalosporins (especially second and third generation), the fluoroquinolones, ampicillin/amoxicillin, and clindamycin. Less
commonly implicated antibiotics are the macrolides (ie, erythromycin, clarithromycin, azithromycin) and other penicillins. Agents
occasionally reported to cause the disease include aminoglycosides, trimethoprim-sulfamethoxazole, metronidazole,
chloramphenicol, tetracycline, imipenem, and meropenem.
Even brief exposure to any single antibiotic can cause C difficile colitis. A prolonged antibiotic course or the use of 2 or more
antibiotics increases the risk of disease. Moreover, antibiotics traditionally used to treat C difficile, vancomycin and
metronidazole, have also been shown to cause disease.[13]
Hospitalized patients who occupy a bed whose previous occupant received antibiotics appear to have an increased risk of C
difficile infection (CDI).[14] A multicenter retrospective (2010-2015) study of 100,615 pairs of patients who sequentially occupied
a given hospital bed found that less than 1% (576 pairs; 0.57%) of subsequent patients developed CDI, regardless of whether
they themselves received antibiotics or not.[14] The association was statistically significant (log-rank P< 0.01).
Proton pump inhibitors
A US Food and Drug Administration (FDA) safety communication on February 8, 2012, described a possible association
between the use of proton pump inhibitors (PPIs) and the development of Clostridium difficile –associated diarrhea (CDAD).[15]
Data were collected from the US Food and Drug Administration’s (FDA's) Adverse Event Reporting System (AERS) and the
medical literature for cases of CDAD in patients undergoing treatment with PPIs.
Many of the adverse event reports involved patients who were elderly, had chronic and/or concomitant underlying medical
conditions, or were taking broad-spectrum antibiotics that could have predisposed them to developing CDAD.[15] The FDA also
reviewed a total of 28 observational studies described in 26 publications. Of these studies, 23 showed a higher risk of C difficile
infection or disease, including CDAD, associated with PPI exposure, compared with no PPI exposure.
Antidepressants
Two related studies documented an increased risk of CDI in adults taking the antidepressants mirtazapine and fluoxetine.[16,
17] In a longitudinal study of 16,781 older adults (mean age, 67.9 y), 404 of whom had been diagnosed with CDI at least once,
major depression was associated with a 36% increase in the odds of developing an infection with C difficile.
In the second study, in which 4047 adult patients had their stools tested for C difficile while they were hospitalized, the odds of
testing positive for the bacterium were twice as high in patients who received mirtazapine or fluoxetine as in those who did not.
[16, 17] None of the other 10 antidepressants that were tested in the study increased the risk of CDI.
Other risk factors
Advanced age (>60 y) and hospitalization (particularly sharing a hospital room with an infected patient, intensive care unit stays,
and prolonged hospital stays) are known risk factors for infection with C difficile. Severe illnesses, immune suppression, and
gastric acid suppression[18] (or bypassing gastric acid via enteral feeds) are also well-established risk factors. In addition, in
recent years, inflammatory bowel disease (IBD) has been implicated as a strong risk factor for C difficile infection (CDI).[9, 19]
Early emergency general surgery has also been associated with a high incidence of CDI, particularly in patients who receive 3
or more postoperative antibiotics and those who undergo bowel resections.[95]
Rarer associations include the following:
Antineoplastic agents, principally methotrexate
Hemolytic-uremic syndrome
Malignancies
Intestinal ischemia
Chronic kidney disease
Necrotizing enterocolitis
Hirschsprung disease
Nonsurgical gastrointestinal procedures, including placement of nasogastric tubes
Genetics/genomics
Two genome-wide association studies (GWAS) found an association between a common polymorphism in the upstream
promoter of the interleukin (IL)-8 gene and an increased risk for both the initial occurrence and the recurrence of CDI.[20, 21]
Neutrophil recruitment to the intestine is thought to be coordinated by IL-8, and the polymorphism in the IL-8 promoter is thought
to influence the manner in which neutrophils are recruited to the intestines when CDI is present.[20, 21]
An additional study looked more specifically at the regulation of the regenerating islet-derived genes (REG) in IBD. Interestingly,
the study found that the activities of all REG genes were upregulated not only in IBD but also in patients with
pseudomembranous colitis.[22] The implication from this study is that the function of the REG family of genes is more
generalized in response to inflammation. These proteins are involved in injury, repair, and growth in the intestine. Also of interest
is that REG proteins in the gut appear to be antimicrobial, with a function similar to lectin.[22]
Toxin A is an enterotoxin that is responsible for the major manifestations of colitis in humans. In a murine model deficient in the
neurokinin-1 receptor, protection against inflammation from toxin A was demonstrated.[23] This protein, which is encoded by the
NK1R gene, functions as the receptor for substance P. Downstream effects from this protective effect included decreased
intestinal levels of tumor necrosis factor (TNF)-alpha and leukocyte myeloperoxidase. The overall suggestion from this study is
that the substance P receptor is very important in the pathogenesis of inflammatory diarrhea.[23]
Further insight into the genetics of C difficile toxin A reveals that the main binding protein is gp96.[24] In addition, it has been
found that C difficile has potent stimulatory activity for the Nod1 gene, and mice who were homozygous knockouts for Nod1 had
increased lethality to CDI despite similar levels of intestinal damage relative to control the mice.[25] Those mice also had
impaired clearance of bacteria and increased translocation of the bacteria. The implication of this study is that Nod1 regulates
the susceptibility to C difficile.[25]
Ultimately, many of the genetic influences on CDI and the clinical course of C difficile colitis likely remain unknown. At this point,
it is understood that subtle differences in the immune system may significantly influence the natural history of C difficile disease.
Epidemiology
Occurrence in the United States
In the United States, C difficile infection (CDI) occurs primarily in hospitalized patients, causing as many as 3 million cases of
diarrhea and colitis per year. Cancer patients are significantly affected by CDI healthcare-associated diarrhea.[26] Diarrhea
caused by C difficile is also linked to 14,000 American deaths annually.[27]
The incidence of reported CDI infection continues to increase. In the 1980s, McFarland et al reported that 7% of patients
admitted to a hospital and 28% of patients who were hospitalized had positive cultures for the organism. By the 1990s, the
incidence of C difficile in hospitalized patients had risen to 30-40 per 100,000 population, and by 2005, to 84 per 100,000
population.
Indeed, in contrast to the incidence rates of other nosocomial infections, which declined from 2000 to 2009, the number of
hospitalized patients with any CDI as a discharge diagnosis more than doubled in the same period, from approximately 139,000
to 336,600. Furthermore, the number of patients with a primary diagnosis of CDI more than tripled, from 33,000 to 111,000.[28]
New CDI populations have emerged, and studies have challenged the notion that C difficile is primarily a hospital infection, as
more cases are being seen in the community.[2, 29, 30] These cases include patients with community-acquired infection and no
previous antibiotic exposure, pregnant women, and patients with inflammatory bowel disease (IBD).[9, 19]
A population-based study from Olmsted County, Minnesota, demonstrated that 41% of the cases of C difficile infection were
community acquired and that the incidence of both community- and hospital-acquired C difficile increased significantly from
1991 to 2005.[2]
International occurrence
The incidence of CDI, as well as deaths attributable to C difficile, has also risen in Europe and Canada. In Canada's Estrie
region of Quebec, the incidence quadrupled in 2003 to 92.2 cases per 100,000 population. In a survey of 97 hospitals across 34
European countries, the incidence of C difficile in hospitalized patients was 41 per 100,000 patient-days.[31]
The worldwide increased incidence of CDI has been attributed to a variety of risk factors, including more elderly patients in the
population, treatment resistance to fluoroquinolones, and the emergence of a newly discovered, more virulent strain of C difficile
(BI/NAP1/027).[32] Additional risk factors toward increasing CDIs include the use of penicillins and clindamycin, as well as an
increased use in the total number of antibiotics in the community.[32]
Age-related demographics
CDI is more common in elderly people, and old age may promote susceptibility to colonization and disease. Cross-infection by C
difficile is common in neonatal units, but neonates do not seem to develop C difficile –associated diarrhea. More recently, there
have been specific populations affected by C difficile that were previously believed to be at low risk, such as young, healthy
persons not exposed to a hospital environment or antimicrobial therapy and young women in a peripartum setting.
A study by Nylund et al suggested an increase in CDI among hospitalized children, especially in those with medical conditions
such as IBD and immunosuppression.[33] Also at risk are individuals hospitalized with conditions that require antibiotic
administration.
Prognosis
Some patients with C difficile colitis with mild disease may recover without specific therapy; however, persistent diarrhea may be
debilitating and can last for several weeks; therefore, treatment is recommended even in mild disease
The use of oral metronidazole or vancomycin produces response rates of greater than 95% in mild to moderate cases, with
symptomatic improvement (diarrhea) in as little as 3-4 days and complete resolution in 7-10 days
Approximately 20-27% of patients treated for a first episode of C difficile colitis relapse after successfully completing therapy,
typically 3 days to 3 weeks after treatment has ended.
Patients who relapse once are at an even greater risk for further relapses; the relapse rate for patients with 2 or more relapses
is 65%.[34]
Adverse outcomes from C difficile infection (CDI) include treatment failure, development of severe or severe-complicated
infection, sepsis and the need for admission to the intensive care unit, need for colectomy, increased length of hospital stay,
need for hospital admission in patients with community-acquired CDI, and mortality.[35] (Mortality rates from C difficile –
associated diarrhea as high as 4.2-6.9% were found in several centers in North America; in a multicenter study from Quebec,
mortality rates increased with age.[36] )
However, there is evidence that reliance primarily on hospital-based studies of CDI, with relatively few studies having been
made of community-acquired cases, may have led researchers to underestimate the burden, but overestimate the severity, of
the condition.[2] Patients with community-acquired CDI are generally younger, with less severe infection relative to hospitalized
patients with CDI.[2]
Severe strains
Several outbreaks have been caused by the North American Pulsed Field type 1 and polymerase chain reaction (PCR) ribotype
027 (NAP1/027) strain. This virulent strain has been associated with increased production of toxins A and B, fluoroquinolone
resistance, and the production of a binary toxin. The role of the binary toxin is not clear, but it may synergistically increase the
virulence of toxins A and B.
Based on the data from the Centers of Disease Control and Prevention (CDC), the virulent strain NAP1/027 has been reported
in most US states and in several countries in Europe.
PCR ribotypes 018 and 056, identified in Europe, have been associated with more severe Cdifficile colitis.[31]
Predictors of severe outcomes in IBD and ulcerative colitis
Patients with IBD are well known to be at an increased risk for CDI. A study identified 3 independent predictors for severe
outcomes in hospitalized IBD patients with CDI: (1) serum albumin less than 3 g/dL, (2) hemoglobin level below 9 g/dL, and (3)
elevated serum creatinine above 1.5 mg/dL.[37]
In another study, investigators found that CDI is associated with a worse long-term outcome in patients with ulcerative colitis.[38]
In the year following treatment for CDI in these patients, an escalation in medical management was noted. In addition,
independent predictors for colectomy within 1 year were infection with C difficile and endoscopically proven severe disease.[38]
Complications
Fulminant colitis
Fulminant colitis is a rare form of CDI, occurring in only 3% of patients but accounting for most of the serious complications.
These include toxic megacolon, colonic perforation, and death. Surgical intervention is usually required in patients who develop
fulminant colitis.
Sailhamer et al conducted a retrospective review of 4796 patients with C difficile colitis, 199 (4.1%) of whom had the fulminant
form, as defined by the need for colectomy or admission to the intensive care unit.[39] The in-hospital mortality rate for fulminant
C difficile colitis was 34.7%. The investigators determined that independent predictors of mortality included the following:
Age of 70 years or older
Severe leukocytosis or leukopenia or bandemia
Cardiorespiratory failure
The presence of all 3 factors resulted in a 57.1% mortality rate; in the absence of all 3, the mortality rate was 0%.[39] The
investigators concluded that despite awareness and treatment of fulminant C difficile colitis, this condition remains highly lethal.
Thus, reliable predictors of mortality should be used to prompt aggressive surgical intervention.[39]
To determine the long-term survival rate, rate of gastrointestinal continuity restoration, and rate of recurrence following an attack
of fulminant C difficile colitis, Miller et al searched a pathologic database for patients with this condition, defined as those who
had a bout of C difficile colitis and whose disease required surgical intervention after failure of medical therapy.[40]
Of the 49 patients who fit the criteria, the investigators found a 30-day mortality rate of 57% (28/49), with an in-hospital mortality
rate of 49%. Moreover, the 5-year survival rate for the long-term survival group was poor, at 38% (16.3% for all patients). Twenty
percent of patients had restored gastrointestinal continuity. One case of recurrence of C difficile colitis was reported.[40]
Toxic megacolon
Toxic megacolon is an acute toxic colitis with dilatation of the colon. This condition is diagnosed clinically in a patient with signs
and symptoms of severe toxicity, the presence of a tender abdomen, and a dilated colon on plain radiograph of the abdomen.
Colonic perforation
Colonic perforation is usually accompanied by abdominal rigidity, involuntary guarding, rebound tenderness, and absent bowel
sounds. Free air may be revealed on abdominal radiographs. Any suspicion of perforation in this setting should prompt
immediate surgical consultation.
Presentation
History
C difficile colonization results in a wide spectrum of clinical conditions, including an asymptomatic carrier state; mild, self-limited
diarrhea; pseudomembranous colitis; and fulminant colitis. Most patients develop diarrhea during or shortly after starting
antibiotics. However, 25-40% of patients may not become symptomatic for as many as 10 weeks after completing antibiotic
therapy.
Symptoms often include the following:
Mild to moderate watery diarrhea that is rarely bloody
Cramping abdominal pain
Anorexia
Malaise
Fever, especially in more severe cases
Physical Examination
Physical examination is generally nonspecific in patients with mild C difficile infection. Fever, signs of dehydration, lower
abdominal tenderness, and/or rebound tenderness (raising the possibility of colonic perforation and peritonitis) may be present.
More concerning signs include marked dehydration, marked abdominal tenderness, and distention, as well as marked rigidity
and decreased bowel sounds. These may indicate the presence of complications such as toxic megacolon, and bowel
perforation.
DDx
Diagnostic Considerations
Although C difficile infection (CDI) is a well-recognized cause of antibiotic-associated diarrhea, other infectious (eg,
salmonellosis, shigellosis) and noninfectious causes for diarrhea should also be considered.
C difficile colitis should be considered in patients with inflammatory bowel disease (IBD). Patients with IBD have several risk
factors that put them at an increased risk for CDI, including immune system impairment due to immunomodulator or biologic
therapy, exposure to antibiotics, and frequent hospitalizations. The diagnosis of CDI is confirmed when the cytotoxin is present
in the patient’s stool sample.
Differential Diagnoses
Crohn Disease
Diverticulitis
Irritable Bowel Syndrome
Malabsorption
Peritonitis and Abdominal Sepsis
Salmonella Infection (Salmonellosis)
Shigellosis
Ulcerative Colitis
Vibrio Infections
Viral Gastroenteritis
Workup
Workup
Approach Considerations
Leukocytosis is common in C difficile infection (CDI) and the white blood cell (WBC) count levels may be quite elevated, a
finding that portends a worse prognosis. Patients with C difficile are also prone to acute kidney injury. Therefore, white blood cell
counts and serum creatinine should be measured in patients with C difficile. Because the presence of leukocytosis and renal
impairment are indicators of severe infection, patients with these findings should be treated initially with oral vancomycin instead
of metronidazole.[5]
In severe disease, electrolyte imbalance, dehydration, hypoalbuminemia, and anasarca may occur, and patients should be
monitored periodically. If surgical intervention is being considered, serum lactate levels and white blood cell counts may aid
clinicians in their decision making.
The Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)
recommend testing for C difficile and its toxins in symptomatic patients only on diarrheal stool, unless there is suspicion of ileus
due to C difficile.[5, 41] When individuals are asymptomatic, stool testing is not recommended unless for epidemiologic studies,
in which case stool cultures are the most sensitive studies.[5, 41]
C difficile testing is not recommended in asymptomatic patients due to the difficulty in distinguishing asymptomatic carriage from
infection in this setting. In addition, repeat testing for C difficile is not recommended following successful treatment in a patient
recently treated for CDI.[5, 41]
Retesting for C difficile is not recommended, particularly for molecular studies, as detection rates and results do not improve,
and there is an associated increase in healthcare costs and the likelihood of false-positive findings.[41]
Stool Examination and Stool Assays

In symptomatic patients, stool testing for C difficile should be performed only on diarrheal samples,[5, 41] and perirectal swabs
are not accepted for testing, unless there is suspicion for ileus due to this organism. Stool testing is not recommended for
asymptomatic patients, as the results are not clinically useful; if such testing is used for epidemiologic purposes, stool culture is
required.[5, 41]
Stool may be positive for blood in the presence of severe colitis, but grossly bloody stools are unusual. Fecal leukocytes are
present in about half of the C difficile colitis cases.
Stool cultures are the most sensitive tests for detecting C difficile and its toxins.[5] Moreover, results of the stool cultures
followed by the identification of a toxigenic culture from an experienced laboratory are the standard used for comparison with
other diagnostic testing.[5] However, despite their role as the gold standard test in patients with suspected C difficile infection
(CDI), stool cultures have a long turnaround time and are resource intensive. Such factors make them too slow for practical
clinical decision making (to treat or not to treat) in affected patients. Consequently, in clinical practice, enzyme immunoassay
(EIA) for C difficile toxin A and B is used more often.
However, although EIA is a rapid test for C difficile toxin A and B, it is not an ideal alternative test for diagnosing CDI, due to it
having a lesser sensitivity than the cell cytotoxin assay (see below). Nonetheless, the poor sensitivity of EIA can be overcome
by obtaining repeat stool specimens or by combining EIA with polymerase chain reaction (PCR) assay or C difficile antigen
(glutamate dehydrogenase [GDH]) EIA.
The following are stool assays for C difficile, from the most sensitive to the least sensitive:
Stool culture is the most sensitive (sensitivity 90-100% and specificity 84-100%), but results are slow and may lead to
delay in diagnosis if used alone
GDH EIA is very sensitive (sensitivity 85-100% and specificity 87-98%); this test detects the presence of GDH produced
by C difficile; positive test results need to be rerun by another assay to verify
Real-time PCR assay may be used to detect C difficile gene toxin as an alternative “gold standard” to stool culture, with
some studies demonstrating excellent sensitivity and specificity, as well as test-retest reliability[3, 42] ; in a study that
used toxigenic culture as the gold standard, the sensitivity was 86%, the specificity was 97%, the positive predictive
value (PPV) was 90%, and the negative predictive value (NPV) was 96%, for C difficile[3] (the PCR test is also
inexpensive and has a fast turnaround time)
The stool cytotoxin test has a sensitivity of 70-100% and a specificity of 90-100%; the diarrheal stool is filtered and then
added to cultured fibroblasts; a positive test result is the demonstration of a cytopathic effect that is neutralized by
specific antiserum; however, this test result is reported only as positive or negative, it is expensive, and it requires
overnight incubation and a tissue culture facility
EIA for detecting toxins A and B is used in most laboratories; it has moderate sensitivity (79-80%) but excellent specificity
(98%); repeat testing is needed if the initial test is negative; EIA for toxin A is available, but it has come to be used less
frequently because of the availability of EIA for toxins A and B
Latex agglutination technique can also be used to detect GDH; however, the sensitivity of this test is poor (48-59%),
although the specificity is 95-96%
Toxin testing has the most important clinical relevance, but its lack of sensitivity is an issue. The Society for Healthcare
Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) suggest an interim strategy; ie, a 2-
step method that has the potential to overcome the sensitivity concern.[5] It would be carried out as follows:
For the initial screening, use EIA detection of GDH
This would be followed by a confirmatory test only for GDH-positive stool specimens by cell cytotoxic assay or toxigenic
culture
In addition, the SHEA and IDSA note that although PCR assay testing appears to be rapid, sensitive, and specific, further
research is needed before it can be recommended for routine testing in cases of suspected CDI.[5]
Biomarkers
A study by El Feghaly et al indicated that fecal inflammatory cytokines may be useful as biomarkers for distinguishing between
C difficile colonization and actual disease. They may also be helpful in determining whether a child with C difficile infection is at
a high risk for prolonged diarrhea. The study involved 65 children who were known to be C difficile positive, as well as
symptomatic and asymptomatic controls. Results included the following[43] :
Fecal cytokines: Elevated in symptomatic children (cases and controls); also elevated at diagnosis in patients with a
significantly greater time to resolution of diarrhea (TTROD)
Fecal chemokine ligand (CXCL)–5 messenger ribonucleic acid (mRNA): Correlation found between abundance at
diagnosis and persistent diarrhea
Phosphorylated p38: Lacks sensitivity, although specific for C difficile infection
Endoscopy
Although endoscopy is not routinely recommended for the diagnosis or management of C difficile infection (CDI), this procedure
may demonstrate the presence of raised, yellowish white, 2- to 10-mm plaques overlying an erythematous, edematous mucosa.
These plaques are termed pseudomembranes (see the following images). Pseudomembranes are observed in 14-25% of
patients with mild C difficile disease and 87% of patients with fulminant disease.
Gross pathology specimen from a case of pseudomembranous colitis revealing the characteristic yellowish plaques.
Gross pathology specimen from a case of pseudomembranous colitis, again demonstrating the characteristic yellowish
plaques.
Colonic pseudomembranes of pseudomembranous colitis. Photographs courtesy of Eric M. Osgard, MD.
Histologic findings
Biopsy of pseudomembranous plaques reveals an inflammatory exudate composed of mucinous debris, fibrin, necrotic epithelial
cells and polymorphonuclear cells. The underlying crypts show disruption by mucous and inflammatory debris. The intervening
mucosa shows edema but is otherwise unremarkable.
Things to consider
Most patients have disease throughout the colon. However, sigmoidoscopy alone may not reveal any abnormality if the disease
is confined to the right colon. Typical pseudomembranes are beyond the limit of flexible sigmoidoscopy in 10% of patients.
Therefore, colonoscopy is more useful.
Endoscopic examination findings may be normal in patients with mild disease or may demonstrate nonspecific colitis in
moderate cases. Endoscopy is the least sensitive means of diagnosing C difficile relative to stool assays.
Sigmoidoscopy and colonoscopy in patients with fulminant colitis may be contraindicated because of the risk of perforation.
Limited proctoscopy, with minimal air insufflation, may be a useful diagnostic tool in case of a diagnostic dilemma.
Computed Tomography Scanning

The American College of Radiology (ACR) recommends abdominal computed tomography (CT) scanning as the imaging
modality of choice for C difficile colitis when pseudomembranous colitis, other complications of C difficile infection (CDI), or other
intra-abdominal pathology is suspected.[4] Marked colonic wall thickening is the most common finding (see the following
images). Other features may include ascites, irregularity of the bowel wall, and pericolonic stranding. In patients with sepsis due
to suspected megacolon, abdominal radiography may be performed instead of CT scanning to establish the presence of
megacolon in a timely manner.
Axial computed tomography scan of pseudomembranous colitis.
Computed tomography scan of pseudomembranous colitis.
Treatment
Approach Considerations
The decision to treat C difficile infection (CDI) and the type of therapy administered depend on the severity of infection, as well
as the local epidemiology and type of C difficile strains present. Except for perioperative prophylaxis, it is recommended that the
use of cephalosporin and clindamycin be restricted for infection prevention.[5] No treatment is necessary for asymptomatic
carriers.
In patients with severe or complicated CDI, oral vancomycin is recommended as first-line therapy due to faster symptom
resolution and fewer treatment failures than when metronidazole is used.
Fecal microbiota transplantation (FMT) is recommended for patients with multiple recurrences of CDI whose conditions persist
despite appropriate antibiotic treatments.[89, 90] A 2018 systematic review and meta-analysis comprising 7 studies with 543
patients with recurrent CDI that compared FMT to standard-of-care management found FMT to hold promise as a treatment
modality in this setting relative to medical therapy alone.[93] There was no significant difference regarding different forms (fresh
vs frozen) and routes (upper vs lower) of FMT administration.
New approaches to the prevention and management of CDI continue to undergo development and investigation.[44] See the
Guidelines section for recent treatment recommendations.
European Society of Clinical Microbiology guidelines
In 2013, The European Society of Clinical Microbiology and Infection released updated guidelines for the treatment of CDI,
which include antibiotic treatment for all but very mild cases. Recommendations include the following[45, 46] :
For patients with nonepidemic, nonsevere CDI clearly induced by antibiotic use, with no signs of severe colitis, it may be
acceptable to stop antibiotic treatment and observe the clinical response for 48 hours.
Antibiotic treatment is recommended for all except very mild cases actually triggered by antibiotic use; suitable
treatments include metronidazole, vancomycin, and fidaxomicin.
For mild/moderate disease, oral metronidazole (500 mg 3 times daily for 10 days) is recommended as the initial
treatment.
In patients for whom oral treatment is inappropriate, fidaxomicin may be used; specific indications include first-line
treatment in patients with recurrence or at risk for recurrence.
For patients with severe CDI, suitable antibiotic regimens include vancomycin (125 mg 4 times daily for 10 days; may be
increased to 500 mg 4 times daily) or fidaxomicin (200 mg twice daily for 10 days).
Use of fidaxomicin is not supported in life-threatening CDI.
Use of oral metronidazole in severe or life-threatening CDI is discouraged.
Fecal transplantation is recommended for multiple recurrent CDI.
For patients with colonic perforation and/or systemic inflammation and deteriorating clinical condition despite antibiotic
treatment, total abdominal colectomy or diverting loop ileostomy combined with colonic lavage is recommended.
Additional management measures include discontinuing unnecessary antimicrobial therapy, adequate replacement of
fluids and electrolytes, avoiding antimotility medications, and reviewing the use of proton pump inhibitors.
CDC promotes improving inpatient antibiotic prescribing to reduce drug resistance and increase
patient safety
In a 2014 CDC analysis of data regarding antibiotic prescribing in hospitalized patients, Fridkin and colleagues estimated that a
30% reduction in the use of broad-spectrum antibiotics would result in a 26% reduction in CDIs.[47, 48] In addition,
improvement in physician antibiotic prescribing habits from overuse and incorrect use would also help to reduce antibiotic
resistance.
The authors recommended the following measures[48] :
Promptly initiate antibiotics for a presumed infection, but first obtain any recommended cultures.
Document and specify the drug's indication, dose, and expected duration of use in the patient's medical chart.
Reassess the patient within 48 hours based on test results and patient examination; adjust the antibiotic regimen (dose,
duration) and/or the agent, or end the antibiotic treatment, as needed.
Surgical intervention
A systematic review and meta-analysis of 12 observational studies with at least moderate quality that comprised 35,057 patients
with inflammatory bowel disease (IBD) with CDI and 929,259 patients without CDI found that although CDI did not appear to
increase the risk of colectomy in the short term in IBD patients, over the long term, it appeared to increase the colectomy risk in
those with IBD overall and in those with ulcerative colitis.[49]
Patients with fulminant colitis and toxic megacolon may require operative intervention, such as colectomy with preservation of
the rectum. These patients’ serum lactate levels and peripheral leukocyte counts may aid in the decision to operate; there is a
significant risk for perioperative mortality with elevated serum lactate levels (5 mmol/L) and leukocytosis (50,000 cells/µL).[5]
Lee and colleagues evaluated clinical factors associated with mortality in emergency colectomies performed for C difficile colitis.
They used the ACS-NSQIP database from 2005 to 2010 to study emergently performed open colectomies for a primary
diagnosis of C difficile colitis on the International Classification of Diseases, Ninth Revision. They compared the preoperative,
intraoperative, and postoperative factors between survivors and nonsurvivors. To study clinical factors that may be associated
with 30-day mortality, they performed multivariate stepwise binomial logistic regression analyses. The overall mortality for this
cohort was 33% (111/335) with a median time to death of 8 days. Survivors were discharged, on average, on postoperative day
24.[50]
On multivariate analysis, those aged 80 years or older were associated with a ninefold increase in the odds of mortality. Other
factors associated with increased mortality were preoperative shock, preoperative dialysis dependence, chronic obstructive
pulmonary disease, and wound class III. In addition, thrombocytopenia, coagulopathy, and renal insufficiency were associated
with a higher mortality. This is the largest series of colectomies performed for C difficile colitis in the literature. The investigators’
findings may be useful in selecting appropriate patients for surgical intervention and may help to define a population where
surgery may not be beneficial.[50]
For more information, see the Medscape Drugs & Diseases articles Toxic Megacolon and Pseudomembranous Colitis Surgery.
Consultations
In patients with complicated CDI, a gastroenterologic consultation may be useful for consideration of a colonoscopic evaluation.
Surgical consultation is recommended in patients with suspected fulminant colitis, toxic megacolon, or peritonitis.
Pharmacologic Management
Cessation of the causative antibiotic is essential when possible, as this may affect the risk of recurrence of infection with C
difficile.[5] Avoid antidiarrheal agents (eg, diphenoxylate with atropine); they have been reported to increase the duration and
severity of symptoms.
Mild to moderate infection
Discontinuing antibiotic therapy may be the only treatment necessary for those with mild antibiotic-associated diarrhea without
fever, abdominal pain, or leukocytosis. This conservative approach allows for the reconstitution of the normal colonic microflora
and markedly reduces the risk of relapse. If ongoing antibiotic therapy is necessary, a treatment can be chosen that is less
frequently associated with CDI, such as intravenous aminoglycosides, sulfonamides, macrolides, tetracycline, or vancomycin.
Patients with mild to moderate diarrhea or colitis, as defined by the absence of leukocytosis, acute kidney injury, fever, sepsis, or
megacolon, should receive antibiotic therapy with oral metronidazole or oral vancomycin (in those who are intolerant to
metronidazole) for 10-14 days. The Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases
Society of America (IDSA) indicate that metronidazole (500 mg PO TID for 10-14 days) is the drug of choice in these patients.[5]
In a retrospective study of 300 patients, a low-dose regimen of oral vancomycin (< 500 mg/day) was as effective as a high-dose
regimen (>500 mg/day) for the treatment of CDIs. Clinical improvement rates for the low- and high-dose regimens were 85%
and 86%, respectively, at 72 hours and 93% and 96%, respectively, at the end of therapy/hospital discharge. Patients on the low
vancomycin dose had lower in-hospital mortality rates (15% versus 23%) but higher C difficile –related hospital readmission
rates (12% vs 5%).[51]
Severe or severe-complicated infection
In patients with suspected severe or complicated CDI, initiate early empirical therapy while the stool tests are pending.[5] Oral
vancomycin (125 mg PO QID for 10-14 days)[5] is recommended as first-line therapy in these cases due to faster symptom
resolution and fewer treatment failures than when metronidazole is used. Vancomycin is not absorbed and acts directly at the
infection site. Symptomatic improvement can be expected within 2-3 days.
Patients with inflammatory bowel disease (IBD) represent a unique population in whom treatment with vancomycin is
recommended regardless of disease severity, owing to the high rate of recurrence of CDI in this population, as well as the
association between CDI and adverse health outcomes, such as surgery and mortality.
In fulminant cases, combined therapy with intravenous metronidazole and vancomycin (PO or PR) is the treatment of choice.[5]
Intravenous vancomycin is ineffective and should not be used for C difficile. The SHEA and IDSA recommend intravenous
metronidazole 500 mg every 8 hours with oral vancomycin 500 mg 4 times per day (and/or 500 mg PR q6h in 100 mL normal
saline as a retention enema).[5]
In several clinical trials, 200 mg of oral fidaxomicin administered every 12 hours for 10 days was found to be noninferior to 125
mg of oral vancomycin administered every 6 hours for 10 days for the treatment of C difficile.[52] There was no difference in
cure rates based on C difficile disease severity. Symptomatic improvement is generally expected within 2-3 days.
In a multicenter retrospective (2013-2014) study of CDI in 72 Spanish patients, fidaxomicin treatment was effective and well
tolerated in patients with severe CDI as well as those at high risk of recurrent disease.[53] The clinical cure rate was 90.3%, with
a 16.7% recurrence rate and a 72.2% sustained cure rate. The investigators found that factors that adversely affected the
sustained cure rate included the presence of cardiovascular disease, acute renal failure, and systemic antibiotic treatment, as
well as the C-reactive protein level measured at the time of the diagnosis.[53]
Relapse
Relapse is generally common, occurring in up to 20-27% of cases. Relapse typically occurs 3 days to 3 weeks after the
treatment is discontinued. Possible reasons for relapse include ongoing risk factors such as antibiotic exposure, failure to
eradicate the organism from the colon, and reinfection from the environment.
In October 2016, the FDA approved bezlotoxumab, a human monoclonal antibody that binds to C difficile toxin B and neutralizes
its effects.[54] It is used with standard-of-care antibiotics to reduce the recurrence of CDI in adults who have a high risk of
recurrence. Approval was based on the results from the global Monocolonal Antibodies For C Difficile Therapy (MODIFY) I and
MODIFY II studies, which showed a single dose of bezlotoxumab (in conjunction with antibiotics) is superior to placebo in
prevention of CDI recurrence through 12 weeks (P = 0.0003 for both trials).[54, 55] High risk in these studies was defined as
age 65 years and older, recent CDI (within 6 months), prior recurrent CDI, compromised immunity, severe CDI (Zar score >1), or
infection with a hypervirulent, binary toxin–positive strain.
In general, management of the first recurrence of CDI is the same as that for the initial episode, including stratification according
to disease severity.[5] However, although metronidazole can be used for the first recurrence of CDI (if it is not severe), the drug
should not be used for subsequent recurrences or for long-term, chronic therapy (risk of cumulative neurotoxicity). Rather, a
second or later recurrences should be managed with vancomycin therapy using a tapered and/or pulse regimen.[5]
The SHEA and IDSA have made no recommendations for preventing recurrent CDI in patients with an underlying infection
requiring continued antimicrobial management.[5]
Probiotics
Probiotics are not recommended for the treatment of active CDI owing to limited data supporting their benefits and a potential
risk for septicemia.[5] However, a meta-analysis that evaluated 34 studies and 4138 patients supported earlier studies indicating
that probiotics can prevent the diarrhea that is associated with antibiotic use.[56]
Fecal Microbiota Transplantation

Fecal microbiota transplantation (FMT) is a novel therapy that involves the transfer of stool from a healthy donor to a patient with
C difficile infection (CDI) in order to reconstitute the normal colonic microbial flora.[96] FMT has been reported to repopulate the
colonic flora, with efficacy rates of greater than 90% demonstrated even in cases refractory to antibiotic therapy.[57] Several
studies have shown that FMT by colonoscopy or enema is an effective approach for patients with recurrent C difficile colitis, with
clinical success rates of up to 95%.[58, 59]
Data regarding fetal microbiota transplantation (FMT) in children with recurrent Clostridium difficile colitis are limited and focus
on colonoscopic administration of FMT. Kronman et al describe 10 consecutive children who received FMT via nasogastric tube
for the treatment of recurrent CDI. The children’s median age was 5.4 years, and 30% were receiving simultaneous
immunosuppression. Median follow-up was 44 days, and 90% of patients resolved their CDI. The authors conclude that FMT via
nasogastric tube appears to be safe, well tolerated, and effective in treating recurrent C difficile colitis in pediatric patients.[60]
Long-term data from a fecal transplantation clinical trial (≥3 mo from the time of fecal transplantation) revealed that of the 77 of
98 patients who could be contacted, 91% did not have a relapse.[6] Of the patients who did relapse, all but 1 were treated
successfully with vancomycin or additional fecal transplantation.[6]
In the first randomized, controlled trial of fecal transplantation, investigators in the Netherlands found fecal transfer to be 3 times
more effective than antibiotics in curing recurrent CDI, leading to the study’s early termination.[7, 8] The study compared 3
treatments: (1) standard vancomycin therapy (500 mg PO QID for 14 days), (2) standard vancomycin therapy plus bowel
lavage, and (3) 4 days of vancomycin therapy (500 mg PO QID) followed by bowel lavage and infusion of donor feces through a
nasoduodenal tube.[7, 8]
In a retrospective study of 83 immunocompromised patients who underwent fecal transplantation for recurrent (12%), refractory
(54%), or severe (34%) CDI, the cure rate after a single transplant was 79% (52 of the 66 patients with at least 12 weeks of
follow-up). Seven of the 9 patients who underwent a second transplant were also cured. Mean follow-up was 12 months.
Serious adverse events, including 2 deaths, occurred within 12 weeks of the transplant in 10 patients (15%).[61]
Of the patients treated with fecal transplantation, 13 of 16 (81%) had resolution of C difficile –associated diarrhea after the first
infusion, and 2 of the 3 remaining patients experienced resolution after receiving a second infusion with feces from a different
donor.[7, 8] By contrast, CDI resolved in only 4 of 13 patients (31%) receiving vancomycin alone and in 3 of 13 patients (23%)
receiving vancomycin with bowel lavage.[7, 8]
However, it should be noted that FMT carries the risk of infection transmission (human immunodeficiency virus [HIV], hepatitis,
and retrovirus). Administration of other bacterial preparations is under investigation.
A meta-analysis of intestinal microbiota transplantation (IMT) in which intestinal microorganisms in a suspension of healthy
donor stool were infused into the intestines of patients with recurrent CDI and pseudomembranous colitis found that out of 317
patients across 27 case series and reports, 92% were successfully treated with this therapy.[62] Adverse effects were
uncommon. Although further study is required, this review supports use of the IMT as a promising treatment for recurrent CDI.
[62]
See the Guidelines section for recent FMT guidelines recommendations.
Prevention
C difficile is now recognized as a major nosocomial pathogen, and universal precautions against it should be implemented. The
following guidelines are recommended when dealing with patients with C difficile colitis[5, 28] :
Use disposable gloves, laboratory coats, and proper washing techniques
Educate the medical and nursing staff, as well as family and visitors, regarding the disease and its epidemiology, and
emphasize compliance with hand hygiene practices (such as washing with soap or antimicrobial soap and water)
Hospital transmission is likely associated with the survival of spores on inanimate objects; therefore, close attention to
cleanliness and disinfective measures are important (eg, use of contact precautions for 48 hours or longer following
resolution of diarrhea, disposable electronic rectal thermometers, chlorine-containing cleansers or other sporicidal
agents), particularly during the patient’s diarrheal period
Isolation of patients who are infected is strongly recommended but often impractical at most hospitals; in such situations,
a dedicated commode for each patient should be provided
The most important preventive measure is the judicious use of antimicrobial agents. Principal CDI prevention recommendations
from the Centers for Disease Control and Prevention (CDC), as well as the Society for Healthcare Epidemiology of America
(SHEA) and the Infectious Diseases Society of America (IDSA), include improved antibiotic therapy, early and accurate CDI
detection, isolation of symptomatic patients, and reduction of C difficile contamination on environmental surfaces in healthcare
settings.[5, 28]
CDI risk is increased 7- to 10-fold during antibiotic use and for 1 month after the drug is discontinued; the risk is approximately
3-fold during the second and third month after discontinuation.[28]
A systematic review and meta-analyses of observational studies have shown evidence of an increased risk for recurrent CDI
among patients who use gastric acid suppressants; the investigators suggest it may be reasonable for clinicians to reassess
whether their patients with CDI need to take these agents.[18]
Guidelines
Guidelines Summary
2017 ISDA and SHEA guidelines on CDI
The following recommendations on Clostridium difficile infection (CDI) were released in February 2018 by the Infectious
Diseases Society of America (ISDA) and Society for Healthcare Epidemiology of America (SHEA).[89, 90]
Diagnosis (adults)
Patients with unexplained and new-onset ≥3 unformed stools in 24 hours are the preferred target population for testing for CDI.
Use a stool toxin test as part of a multistep algorithm (ie, glutamate dehydrogenase [GDH] plus toxin; GDH plus toxin, arbitrated
by nucleic acid amplification test [NAAT]; or NAAT plus toxin) rather than NAAT alone for all specimens when there are no
preagreed institutional criteria for patient stool submission.
Use NAAT alone or a multistep algorithm for testing (ie, GDH plus toxin; GDH plus toxin, arbitrated by NAAT; or NAAT plus toxin)
rather than a toxin test alone when there are preagreed institutional criteria for patient stool submission.
Do not perform repeat testing (within 7 days) during the same episode of diarrhea and do not test stool from asymptomatic
patients, except for epidemiologic studies.
Diagnosis (pediatric)
Because of the high prevalence of asymptomatic carriage of toxigenic C difficile in infants, testing for CDI should never be
routinely recommended for neonates or infants ≤12 months of age with diarrhea.
C difficile testing should not be routinely performed in children with diarrhea who are 1-2 years of age unless other infectious or
noninfectious causes have been excluded.
In children ≥2 years of age, C difficile testing is recommended for patients with prolonged or worsening diarrhea and risk factors
(eg, underlying inflammatory bowel disease or immunocompromising conditions) or relevant exposures (eg, contact with the
healthcare system or recent antibiotics).
Treatment (adults)
Discontinue therapy with the inciting antibiotic agent(s) as soon as possible, as this may influence the risk of CDI recurrence.
Antibiotic therapy for CDI should be started empirically for situations where a substantial delay in laboratory confirmation is
expected, or for fulminant CDI.
Either vancomycin or fidaxomicin is recommended over metronidazole for an initial episode of CDI. The dosage is vancomycin
125 mg orally 4 times per day or fidaxomicin 200 mg twice daily for 10 days.
In settings where access to vancomycin or fidaxomicin is limited, metronidazole is suggested for an initial episode of nonsevere
CDI only. The suggested dosage is metronidazole 500 mg orally 3 times per day for 10 days. Avoid repeated or prolonged
courses due to the risk of cumulative and potentially irreversible neurotoxicity.
For fulminant CDI, vancomycin administered orally is the regimen of choice. If ileus is present, vancomycin can also be
administered per rectum. The vancomycin dosage is 500 mg orally 4 times per day and 500 mg in approximately 100 mL normal
saline per rectum every 6 hours as a retention enema. Intravenously administered metronidazole should be administered
together with oral or rectal vancomycin, particularly if ileus is present. The metronidazole dosage is 500 mg intravenously every
8 hours.
If surgical management is necessary for severely ill patients, perform subtotal colectomy with preservation of the rectum.
Diverting loop ileostomy with colonic lavage followed by antegrade vancomycin flushes is an alternative approach that may lead
to improved outcomes.
Treat a first recurrence of CDI with oral vancomycin as a tapered and pulsed regimen rather than a second standard 10-day
course of vancomycin; OR treat a first recurrence of CDI with a 10-day course of fidaxomicin rather than a standard 10-day
course of vancomycin; OR treat a first recurrence of CDI with a standard 10-day course of vancomycin rather than a second
course of metronidazole if metronidazole was used for the primary episode.
Fecal microbiota transplantation is recommended for patients with multiple recurrences of CDI whose conditions have failed
appropriate antibiotic treatments.
Treatment (pediatric)
Either metronidazole or vancomycin is recommended for the treatment of children with an initial episode or first recurrence of
nonsevere CDI.
For children with an initial episode of severe CDI or with a second or greater episode of recurrent CDI, oral vancomycin is
recommended over metronidazole.
2018 BSG and HIS guidelines on FMT
In September 2018, the British Society of Gastroenterology (BSG) and Healthcare Infection Society (HIS) released guidelines
on best practices of fecal microbiota transplantation (FMT) for the treatment of CDI and for potential non-CDI indications in
adults.[91]
FMT should be offered to patients with CDI who have had at least 2 recurrences and to patients who have had one recurrence
and also have risk factors for additional recurrences.
Consider FMT in cases of refractory CDI.
Do not administer FMT as the initial treatment for CDI.
Recommend that FMT be considered for recurrent CDI only after recurrence following resolution of an episode of CDI treated
with appropriate antimicrobials for at least 10 days.
Recommend considering extended/pulsed vancomycin and/or fidaxomicin before FMT is considered for recurrent CDI.
In cases of severe or complicated CDI, before offering FMT, recommend considering treatment with medications such as
fidaxomicin and bezlotoxumab, which are associated with reduced risk of recurrence.
Recommend that FMT be offered after initial failure of FMT.
Clinicians should follow-up FMT recipients for at least 8 weeks in total.
Recommend that patients be warned about short-term adverse effects of FMT, particularly possible self-limiting GI symptoms,
and be advised that serious adverse effects are rare.
Recommend that, after enteral tube administration, the tube be removed and oral water given following 30 minutes after tube
administration.
Recommend that FMT be avoided in patients who have anaphylactic food allergy.
Suggest that FMT be offered with caution to patients who have CDI and decompensated chronic liver disease.
Recommend that FMT be offered with caution to immunosuppressed patients, in whom FMT appears to be efficacious without
significant additional adverse effects.
Recommend that patients who are immunosuppressed and at risk of severe infection if exposed to Epstein–Barr virus (EBV) or
cytomegalovirus (CMV) receive FMT only from donors who are negative for Epstein-Barr virus (EBV) and cytomegalovirus
(CMV).
Suggest that people be considered as potential FMT donors only if they are 18 to 60 years of age and have a body mass index
of 18 to 30 kg/m2.
Medication
Medication Summary
Pharmacologic therapy should be tailored according to the severity of C difficile infection (CDI). Treatment is not indicated for
asymptomatic carriers. In very mild cases (ie, patients without fever, abdominal pain, or leukocytosis), in patients who do not
have other comorbidities, cessation of causative antibiotics may be the only treatment necessary.
Approximately 15-25% of patients respond to conservative therapy, which allows for the reconstitution of normal colonic flora
and reduces the risk of relapse. Specific therapy aimed at eradicating C difficile is indicated if symptoms are persistent or if
antibiotics cannot be discontinued safely.
Oral metronidazole and oral vancomycin have similar efficacy rates in treating diarrhea caused by C difficile in mild to moderate
infection but not in severe disease. Whereas metronidazole is the recommended first-line treatment for mild to moderate
disease without complications, vancomycin is recommended first-line therapy for severe infection or for patients with risk factors
for adverse outcomes, such as advanced age, critical illness, overall debility, or inflammatory bowel disease (IBD). Vancomycin,
rifaximin, and fidaxomicin are useful in recurrent or persistent cases.
The oral administration of these medications is the preferred route, because C difficile remains within the colonic lumen without
invading the colonic mucosa. Vancomycin is poorly absorbed in the intestinal tract, thereby promoting high concentrations within
the intestines while significantly reducing the prevalence of adverse systemic effects.
The Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)
recommend a regimen of metronidazole (500 mg PO TID for 10-14 days) as first-line therapy for mild to moderate disease
without complications (lower cost and similar efficacy to PO vancomycin in these patients).[5] For patients who are unable to
tolerate oral medication, intravenous metronidazole is effective.
A study by Louie et al compared vancomycin (125 mg PO QID) with fidaxomicin (200 mg PO BID).[63] The study showed that
fidaxomicin therapy had a similar efficacy and resulted in a significantly lower rate of recurrence of CDI not associated with the
epidemic North American Pulsed Field type 1 strains. Fidaxomicin was approved by the FDA in May 2011.
In another study, a review of 11 trials (1463 adult patients total) comparing metronidazole with vancomycin or another agent,
combined agents, or placebo, neither vancomycin nor fidaxomicin were clearly superior for the initial treatment of CDI. One
study in the review, however, showed CDI recurrence in only 15% of patients treated with fidaxomicin, compared with 25% of
patients treated with vancomycin.[64]
As noted above, for severe cases, vancomycin (125 mg PO QID for 10 days) is the recommended first-line therapy. Higher
dosing (250 mg PO [or per nasogastric tube] QID) may be used in situations such as ileus. Excretion of the drug into bile and
exudation from the inflamed colon results in bactericidal levels in feces. Intravenous vancomycin is ineffective and should not be
used for C difficile. The SHEA and IDSA recommend metronidazole (500 mg IV q8h) with vancomycin (500 mg PO QID and/or
500 mg PR q6h in 100 mL normal saline as a retention enema) for severe or complicated cases of CDI.[5]
In several clinical trials, 200 mg of oral fidaxomicin administered every 12 hours for 10 days has been noninferior to 125 mg of
oral vancomycin administered every 6 hours for 10 days for the treatment of C difficile.[52] No difference in cure rates based on
C difficile disease severity was reported. Symptomatic improvement is generally expected within 2-3 days.
In a multicenter study including 1105 subjects with C difficile–associated diarrhea, 183 of whom had solid tumors or hematologic
malignancies, fidaxomicin treatment was superior to vancomycin treatment in cancer patients, resulting in higher cure and
sustained response rates for diarrhea, shorter time to resolution of diarrhea (TTROD), and fewer recurrences.[65, 66]
Cure rates for diarrhea in the study were lower overall in cancer patients (79.2%) than in others (88.6%).[66] Cure rates for
noncancer patients were approximately the same with fidaxomicin (88.5%) as with vancomycin (88.7%); however, those for
cancer patients were higher with fidaxomicin than with vancomycin (85.1% vs 74.0%), although the difference was not
statistically significant. Median TTRODs in noncancer patients were 54 hours with fidaxomicin and 58 hours with vancomycin;
those in cancer patients were 74 and 123 hours, respectively.
In the same study, the risk of recurrence was approximately twice as high with vancomycin as with fidaxomicin, regardless of
whether the patients had cancer or not, but because cure and recurrence outcomes were better with fidaxomicin than with
vancomycin in cancer patients, the relative odds of sustained response at 28 days in these patients were more than 2.5-fold
higher for fidaxomicin than for vancomycin.[66]
Relapse
Relapse occurs in 20-27% of patients treated with metronidazole or vancomycin. Most recurrences occur 3 days to 3 weeks
after discontinuing antibiotic treatment. Once a patient has 1 relapse, the risk for a 2nd relapse is 45%.
Bezlotoxumab is a human monoclonal antibody that binds to C difficile toxin B and neutralizes its effects. It is used with the
standard of care antibiotics to reduce recurrence of CDI in adults who are at a high risk of recurrence. Approval was based on
the results from the global MODIFY I and MODIFY II studies that showed a single dose of bezlotoxumab is superior to placebo
in the prevention of CDI recurrence through 12 weeks (P = 0.0003 for both trials).[55]
Age greater than 65, severe underlying illnesses, and ongoing antibiotic treatments during C difficile therapy are all risk factors
for recurrence. Recurrent infection tends to occur in patients who mount a poor host immune response to C difficile. Persistent
disruption of the colonic microbial flora also confers an increased risk. Recurrent infection can result from reinfection with the
same strain or a different strain of C difficile.
For the first relapse, the choice of antibiotic should be based on the severity of C difficile diarrhea/colitis. Mild symptoms of
recurrence in patients who are otherwise well may be managed without further antibiotic therapy. Initial recurrence that is not
severe can be treated with metronidazole. For subsequent recurrences, patients may benefit from vancomycin in a prolonged
tapered and/or pulse regimen or fidaxomicin with or without probiotics. Rifaximin is also a potential option.
Probiotics
Probiotics are not recommended as a single agent for the treatment of active CDI owing to limited data supporting their benefit
and a potential risk for septicemia.[5] Use of Saccharomyces boulardii and Lactobacillus species have shown mixed results in
reducing the risk of CDI relapse. However, S boulardii has generated interest for the treatment of CDI, because it seems to
inhibit the effects of toxins A and B on the human colonic mucosa.
Potential therapies
Rifaximin after treatment with vancomycin may reduce the risk of relapse, but rifaximin is not yet FDA approved for this
indication.
Nitazoxanide, a medication used to treat parasites, has been shown to be as effective as vancomycin in a clinical trial for the
treatment of C difficile.
A review of 10 clinical trials evaluating the treatment of an initial episode of CDI showed that nitazoxanide and teicoplanin did
not demonstrate inferiority relative to vancomycin and metronidazole.[67] However, other antimicrobials, including rifampin, and
the toxin-binding polymer tolevamer, did show inferiority compared with vancomycin and metronidazole.[67]
Intravenous immunoglobulin (IVIG), which contains C difficile antitoxin, has been reported as an effective adjunctive treatment
for refractory and severe cases of C difficile colitis/diarrhea. In some individuals, a poor host immune response to C difficile may
be a risk factor for the lack of clearance of C difficile and may be the reason for the benefit of IVIG.
A review of the literature and a retrospective review of 21 of 1230 patients with CDI who received IVIG showed that conventional
treatments were used for an average of 8 days before IVIG was administered.[68] All of the patients reviewed had radiologic
pancolitis or clinical ileus. Following treatment with IVIG, 9 (43%) of the patients survived with resolution of their colitis, whereas
12 (57%) of the patients died. Patients who survived showed resolution of their symptoms after an average of 10 days (range, 2-
20 d).[68]
Cholestyramine binds toxins A and B of C difficile, but the clinical experience of different investigators has shown marked
variation in results. Cholestyramine binds vancomycin and should not be used concurrently with vancomycin therapy. Although
not as effective as primary therapy for C difficile, the advantage of anion-binding resins is that they do not alter the colonic flora.
Other investigational therapies include the following:
Tolevamer: A toxin-binding polymer with no antimicrobial properties
The antibiotics ramoplanin and OPT-80 (poor intestinal absorption)
C difficile vaccination
Antibiotics, Other
Class Summary
The purpose of treatment is to eradicate C difficile infection (CDI) and/or promote restoration of the normal colonic flora.
Metronidazole (Flagyl)
Metronidazole is recommended as the treatment of choice for mild to moderate cases of CDI. This agent provides effective
therapy, with reported response rates from 95-100%. Its in vitro activity is bactericidal and dose dependent. Standard dosing has
been shown to promote fecal concentrations capable of a 99.99% reduction of C difficile.
Metronidazole is relatively inexpensive. Intravenous (IV) metronidazole may be administered to those patients who cannot
tolerate oral (PO) medications because of its potential to accumulate in the inflamed colon. However, the IV route is not as
effective as the PO route.
Bacitracin
Bacitracin inhibits the formation of major components of the bacterial cell wall and is bactericidal. This agent is used as an
alternative therapy for CDI, but it is expensive and not as effective as metronidazole or vancomycin in clinical trials and is thus
without sufficient data to warrant its use. Bacitracin is bitter and must be specially prepared in capsule form to prevent nausea.
This agent is administered PO, and it is only negligibly absorbed from the gastrointestinal (GI) tract.
Glycopeptides
Class Summary
Oral vancomycin does not get absorbed and acts directly at the site of infection.
Vancomycin (Firvanq, Vancocin)

Vancomycin has excellent in vitro activity against C difficile. This agent kills the organism by inhibiting cell wall synthesis.
Significant luminal levels after administration of PO vancomycin can be obtained because the drug is poorly absorbed from the
GI tract. Its major disadvantage, however, is that it is relatively expensive.
Because of the cost and the concern over the emergence of vancomycin-resistant enterococci strains, this agent should be
reserved for patients who cannot tolerate or do not respond to metronidazole, pregnant patients, and patients younger than 10
years.
Vancomycin is also preferred for severe cases and in patients who are high risk. Unlike IV metronidazole, IV vancomycin is not
excreted into the GI lumen; therefore, it is difficult to deliver effective IV doses. Available orally as capsules or oral solution.
Macrolides
Class Summary
Fidaxomicin was approved in 2011 by the FDA for the treatment of C difficile -associated diarrhea in adults. This agent has a
narrower antimicrobial spectrum and alters the gut microflora less than do metronidazole and vancomycin.
Fidaxomicin (Dificid)
Fidaxomicin is a macrolide antibiotic indicated for C difficile–associated diarrhea in adults. This agent is bactericidal against C
difficile in vitro, inhibiting RNA synthesis by RNA polymerases.
Monoclonal Antibodies
Class Summary
Human monoclonal antibodies that bind to C difficile toxins may be considered with standard-of-care antibiotics to prevent
recurrent infection.
Bezlotoxumab (Zinplava)
Bezlotoxumab is a human monoclonal antibody that binds to C difficile toxin B, thereby neutralizing its effects. It is administered
as a single IV infusion in conjunction with standard-of-care antibiotics to reduce recurrence of C difficile infection (CDI) in adults
who are at a high risk for recurrence.
Bile Acid Sequestrants
Class Summary
Bile acid sequestrants bind C difficile toxin and other proteins. Although not as effective as primary therapy for C difficile, the
advantage of bile acid sequestrant therapy is that it does not alter the gut microflora.
Cholestyramine (Questran)
Cholestyramine is used to treat diarrhea associated with pseudomembranous colitis. This agent forms a nonabsorbable
complex with bile acids in the intestine, which, in turn, inhibits the enterohepatic reuptake of intestinal bile salts.
Note that cholestyramine binds vancomycin, which precludes combination therapy. This agent is available as a powder that
must be mixed with water prior to ingestion. The efficacy of cholestyramine is inferior to that of metronidazole or vancomycin, but
the drug may have a role under certain circumstances (eg, in patients who continue to relapse). This agent is not absorbed from
the GI tract.
Questions & Answers

Overview
What causes Clostridium difficile (C diff) colitis?
What are common symptoms of Clostridium difficile (C diff) colitis?
What are the common physical findings in individuals with Clostridium difficile (C diff) colitis?
When should a diagnosis of Clostridium difficile (C diff) colitis be suspected?
Which lab tests should be performed in the evaluation for Clostridium difficile (C diff) infection (CDI)?
Which are the most sensitive stool assays for assessing Clostridium difficile (C diff) infection (CDI)?
Which imaging study is most useful for diagnosis of Clostridium difficile (C diff) colitis?
Is endoscopy useful for diagnosing Clostridium difficile (C diff) colitis?
What are the treatment options for Clostridium difficile (C diff) colitis?
What is the treatment for relapsed Clostridium difficile (C diff) colitis?
Is fecal microbiota transplantation effective in the treatment of Clostridium difficile (C diff) infection (CDI)?
What is Clostridium difficile (C diff)?
What is the prevalence of Clostridium difficile (C diff) colitis in hospitalized patients?
When should Clostridium difficile (C diff) colitis be suspected?
What is the rate of recurrence of Clostridium difficile (C diff) infection (CDI)?
How does Clostridium difficile (C diff) colitis develop?
What role do antibiotics have in the proliferation of Clostridium difficile (C diff)?
What is the difference between the 2 toxins produced by Clostridium difficile (C diff)?
What are the manifestations of the NAP1 strain of Clostridium difficile (C diff)?
What is the etiology of Clostridium difficile (C diff) colitis?
Which antibiotics increase the risk of developing Clostridium difficile (C diff) colitis?
Does the use of proton pump inhibitors (PPIs) increase the risk for Clostridium difficile (C diff) colitis?
Which antidepressants increase the risk for Clostridium difficile (C diff) infection (CDI)?
What are the risk factors for Clostridium difficile (C diff) colitis infection (CDI)?
Which genes increase the risk for Clostridium difficile (C diff) infection (CDI)?
What is the prevalence of Clostridium difficile (C diff) infection (CDI) in the US?
Has the incidence of reported Clostridium difficile (C diff) infection (CDI) increased over time?
What is the incidence of community-acquired Clostridium difficile (C diff) infection (CDI) compared to hospital-acquired C diff
infection?
What is the global incidence of Clostridium difficile (C diff) infection (CDI)?
How does Clostridium difficile (C diff) infection (CDI) affect different age groups?
Is treatment always necessary for Clostridium difficile (C diff) colitis?
Is oral metronidazole or vancomycin effective in the treatment of Clostridium difficile (C diff) colitis?
How common is relapse of Clostridium difficile (C diff) colitis?
What are the complications and mortality rates associated with Clostridium difficile (C diff) infection (CDI)?
What is the prognosis for North American Pulsed Field type 1 and polymerase chain reaction (PCR) ribotype 027 (NAP1/027)
strain of Clostridium difficile (C diff)?
What are the prognostic factors for severe outcomes in hospitalized patients with Clostridium difficile (C diff) infection (CDI) who
have IBD?
What is fulminant colitis and how common is it as a complication of Clostridium difficile (C diff) infection (CDI)?
What is the prognosis of fulminant Clostridium difficile (C diff) colitis?
How is the toxic megacolon complication of Clostridium difficile (C diff) infection (CDI) diagnosed?
What are signs of colonic perforation in Clostridium difficile (C diff) infection?
Presentation
What are the symptoms of Clostridium difficile (C diff) colitis?
What are the physical findings in Clostridium difficile (C diff) colitis?
DDX
What differential diagnoses should be considered in suspected Clostridium difficile (C diff) colitis?
What are the differential diagnoses for Clostridium Difficile Colitis?
Workup
What are the roles of WBC count and serum creatinine in the evaluation of Clostridium difficile (C diff) colitis?
What are the recommendations for stool testing in Clostridium difficile (C diff) infection (CDI)?
When is retesting for Clostridium difficile (C diff) infection (CDI) recommended?
How should stool testing for Clostridium difficile (C diff) infection (CDI) be performed?
Is blood usually present in the stool of patients with Clostridium difficile (C diff) colitis?
Are stool cultures recommended for diagnosing Clostridium difficile (C diff) colitis?
Is enzyme immunoassay (EIA) used to diagnose Clostridium difficile (C diff) infection (CDI)?
What are the most sensitive stool assays for detecting Clostridium difficile (C diff) infection (CDI)?
What are the recommendations for toxin testing in stool in individuals with suspected Clostridium difficile (C diff) infection (CDI)?
Which biomarkers may be useful for distinguishing between Clostridium difficile (C diff) colonization and actual disease?
What endoscopy findings indicate Clostridium difficile (C diff) infection (CDI)?
What does biopsy of pseudomembranous plaques show in Clostridium difficile (C diff) colitis?
Why is colonoscopy more useful than sigmoidoscopy in suspected Clostridium difficile (C diff) colitis?
Can endoscopic exam findings be normal in patients with Clostridium difficile (C diff) infection (CDI)?
Are sigmoidoscopy and colonoscopy indicated in fulminant Clostridium difficile (C diff) colitis?
Which imaging modality does the ACR recommend in suspected Clostridium difficile (C diff) colitis?
What are the common findings of CT scanning in Clostridium difficile (C diff) colitis?
Treatment
What should be considered in making treatment decisions in Clostridium difficile (C diff) infection (CDI)?
What are the ESCMI guidelines for the treatment of Clostridium difficile (C diff) infection (CDI)?
What are the CDC recommendations regarding antibiotic prescribing in hospitalized patients to reduce Clostridium difficile (C
diff) infection (CDI)?
Does Clostridium difficile (C diff) infection (CDI) increase the risk of colectomy in patients with IBD?
Do patients with fulminant Clostridium difficile (C diff) colitis and toxic megacolon require surgery?
What are the outcomes of emergency colectomy in Clostridium difficile (C diff) colitis?
When should consultations be considered in Clostridium difficile (C diff) colitis?
Does cessation of antibiotics that cause Clostridium difficile (C diff) colitis lower the risk of recurrence?
How is mild diarrhea treated in Clostridium difficile (C diff) infection (CDI)?
How is severe or complicated Clostridium difficile (C diff) colitis treated?
How is Clostridium difficile (C diff) infection (CDI) treated in patients with IBD?
How are fulminant cases of Clostridium difficile (C diff) colitis treated?
Is oral fidaxomicin effective in the treatment of Clostridium difficile (C diff) colitis?
How common is relapse of Clostridium difficile (C diff) colitis?
Is bezlotoxumab effective in reducing the recurrence of Clostridium difficile (C diff) colitis?
Are probiotics recommended in the treatment of Clostridium difficile (C diff) infection (CDI)?
How effective is fecal microbiota transplantation (FMT) in the treatment of recurrent Clostridium difficile (C diff) colitis?
Is fecal microbiota transplantation (FMT) an effective treatment of recurrent Clostridium difficile (C diff) colitis in children?
Is fecal microbiota transplantation (FMT) an effective cure for recurring Clostridium difficile (C diff) colitis?
What risks are associated with fecal microbiota transplantation (FMT) in Clostridium difficile (C diff) colitis?
Is intestinal microbiota transplantation (IMT) effective as treatment for recurrent Clostridium difficile (C diff) colitis?
What are the guidelines for preventing nosocomial transmission of Clostridium difficile (C diff)?
How is Clostridium difficile (C diff) infection (CDI) prevented?
Guidelines
What are IDSA/SHEA diagnostic and treatment guidelines for Clostridium difficile infection (CDI)?
What are the BSG/HIS guidelines on best practices for fecal microbiota transplantation (FMT) to treat Clostridium difficile
infection (CDI)?
Medications
When should medication therapy be considered in the treatment of Clostridium difficile (C diff) infection (CDI)?
Which medications are recommended in the treatment of Clostridium difficile (C diff) colitis?
What are the recommended metronidazole regimens in the treatment of Clostridium difficile (C diff) colitis?
Is fidaxomicin effective as a treatment for the North American Pulsed Field type 1 (NAP1) strains of Clostridium difficile (C diff)?
Is metronidazole more effective than other agents in the initial treatment of Clostridium difficile (C diff) infection?
What is the recommended medication treatment for severe cases of Clostridium difficile (C diff) colitis?
Is fidaxomicin as effective as vancomycin in the treatment of Clostridium difficile (C diff) infection (CDI)?
Which medications are most effective in treating Clostridium difficile (C diff) colitis in patients with cancer?
What is the prevalence of relapse in patients treated with metronidazole or vancomycin for Clostridium difficile (C diff) colitis?
What is bezlotoxumab?
What are risk factors for recurrence of Clostridium difficile (C diff) infection (CDI)?
What are the determining factors in choosing an antibiotic for Clostridium difficile colitis (C diff) recurrence?
Are probiotics beneficial in the treatment of Clostridium difficile (C diff) colitis?
Is rifaximin FDA approved for prevention of Clostridium difficile (C diff) colitis relapse?
Is nitazoxanide an effective treatment for Clostridium difficile (C diff) colitis?
Is IVIG an effective adjunctive treatment for Clostridium difficile (C diff) colitis?
Is cholestyramine an effective treatment for Clostridium difficile (C diff) colitis?
What therapies are being investigated for the treatment of Clostridium difficile (C diff) colitis?
Which medications in the drug class Bile Acid Sequestrants are used in the treatment of Clostridium Difficile Colitis?
Which medications in the drug class Monoclonal Antibodies are used in the treatment of Clostridium Difficile Colitis?
Which medications in the drug class Macrolides are used in the treatment of Clostridium Difficile Colitis?
Which medications in the drug class Glycopeptides are used in the treatment of Clostridium Difficile Colitis?
Which medications in the drug class Antibiotics, Other are used in the treatment of Clostridium Difficile Colitis?
Contributor Information and Disclosures
Author
Faten N Aberra, MD, MSCE Assistant Professor of Medicine, Division of Gastroenterology, Hospital of the University of
Pennsylvania, University of Pennsylvania School of Medicine
Faten N Aberra, MD, MSCE is a member of the following medical societies: American College of Gastroenterology, American
Gastroenterological Association, Crohn's and Colitis Foundation of America, Sigma Xi
Disclosure: Nothing to disclose.
Coauthor(s)
Jennifer A Curry, MD, MPH Attending Physician, Infectious Disease Clinic, Naval Medical Center Portsmouth; Assistant
Professor of Medicine, Uniformed Services University of the Health Sciences
Jennifer A Curry, MD, MPH is a member of the following medical societies: American College of Physicians, American Society
for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America
Chief Editor
BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine
BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American
College of Gastroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy
Acknowledgements
Acknowledgments
The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the
Department of the Navy, Department of Defense, or the US government.
LCDR Jennifer Curry is a military service member. This work was prepared as part of official duties. Title 17 U.S.C. §105
provides that ‘Copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C.
§101 defines a U.S. Government work as a work prepared by a military service member or employee of the US Government as
part of that person’s official duties.
Additional Contributors
Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious
Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of
Physicians, and Infectious Diseases Society of America
Gary L Gorby, MD Associate Professor, Departments of Internal Medicine and Medical Microbiology and Immunology, Division
of Infectious Diseases, Creighton University School of Medicine; Associate Professor of Medicine, University of Nebraska
Medical Center; Associate Chair, Omaha Veterans Affairs Medical Center
Gary L Gorby, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association,
American Society for Microbiology, Infectious Diseases Society of America, and New York Academy of Sciences
Craig A Gronczewski, MD Clinical Assistant Professor, Robert Wood Johnson Medical School, University of Medicine and
Dentistry of New Jersey; Consulting Staff, Princeton Medical Center; Consulting Staff, Robert Wood Johnson University Hospital
Craig A Gronczewski, MD is a member of the following medical societies: Alpha Omega Alpha and American College of
Emergency Physicians
Braden R Hale, MD, MPH Assistant Clinical Professor, Department of Internal Medicine, University of California at San Diego;
Consulting Staff, Department of Internal Medicine, Division of Infectious Diseases, Naval Medical Center at San Diego
Duane R Hospenthal, MD, PhD, FACP, FIDSA Adjunct Professor of Medicine, Department of Medicine, University of Texas
Health Science Center at San Antonio
Duane R Hospenthal, MD, PhD, FACP, FIDSA is a member of the following medical societies: Alpha Omega Alpha, American
College of Physicians, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine
and Hygiene, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases
Society of America, International Society for Human and Animal Mycology, International Society for Infectious
Diseases,International Society of Travel Medicine, and Medical Mycology Society of the Americas
Joseph F John Jr, MD, FACP, FIDSA, FSHEA Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical
University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs
Medical Center
Jonathan P Katz, MD Assistant Professor of Medicine, Department of Medicine, University of Pennsylvania School of Medicine
Jonathan P Katz, MD is a member of the following medical societies: American Gastroenterological Association and American
Society for Gastrointestinal Endoscopy
Joseph Lee, MD Staff Physician, Department of Medicine, Walter Reed Army Medical Center
Waqar A Qureshi, MD Associate Professor of Medicine, Chief of Endoscopy, Department of Internal Medicine, Division of
Gastroenterology, Baylor College of Medicine and Veterans Affairs Medical Center
Waqar A Qureshi, MD is a member of the following medical societies: American College of Gastroenterology, American College
of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy;
Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
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Clostridium Difficile Colitis

Signs and symptoms

Symptoms of C difficile colitis often include the following:

Mild to moderate watery diarrhea that is rarely bloody

Cramping abdominal pain

Fever: Especially in more severe cases

Lower abdominal tenderness

Rebound tenderness: Raises the possibility of colonic perforation and peritonitis

See Clinical Presentation for more detail.

Albumin levels: Hypoalbuminemia may accompany severe disease

Imaging studies and procedures

Computed tomography scan of pseudomembranous colitis.

See Workup for more detail.

Asymptomatic carriers: No treatment is necessary

See Treatment and Medication for more detail.

Proton pump inhibitors

Other risk factors

Rarer associations include the following:

Antineoplastic agents, principally methotrexate

Chronic kidney disease

Nonsurgical gastrointestinal procedures, including placement of nasogastric tubes

Predictors of severe outcomes in IBD and ulcerative colitis

Age of 70 years or older

Severe leukocytosis or leukopenia or bandemia

Symptoms often include the following:

Mild to moderate watery diarrhea that is rarely bloody

Cramping abdominal pain

Fever, especially in more severe cases

Irritable Bowel Syndrome

Peritonitis and Abdominal Sepsis

Salmonella Infection (Salmonellosis)

Stool Examination and Stool Assays

For the initial screening, use EIA detection of GDH

Phosphorylated p38: Lacks sensitivity, although specific for C difficile infection

Colonic pseudomembranes of pseudomembranous colitis. Photographs courtesy of Eric M. Osgard, MD.

Computed Tomography Scanning

Axial computed tomography scan of pseudomembranous colitis.

Computed tomography scan of pseudomembranous colitis.

European Society of Clinical Microbiology guidelines

Use of fidaxomicin is not supported in life-threatening CDI.

Use of oral metronidazole in severe or life-threatening CDI is discouraged.

Fecal transplantation is recommended for multiple recurrent CDI.

The authors recommended the following measures[48] :

Mild to moderate infection

Severe or severe-complicated infection

Fecal Microbiota Transplantation

See the Guidelines section for recent FMT guidelines recommendations.

Use disposable gloves, laboratory coats, and proper washing techniques

2018 BSG and HIS guidelines on FMT

Consider FMT in cases of refractory CDI.

Do not administer FMT as the initial treatment for CDI.

Recommend that FMT be offered after initial failure of FMT.

Clinicians should follow-up FMT recipients for at least 8 weeks in total.

Other investigational therapies include the following:

Tolevamer: A toxin-binding polymer with no antimicrobial properties

The antibiotics ramoplanin and OPT-80 (poor intestinal absorption)

Vancomycin (Firvanq, Vancocin)

Bile Acid Sequestrants

Questions & Answers

What causes Clostridium difficile (C diff) colitis?

What are common symptoms of Clostridium difficile (C diff) colitis?

When should a diagnosis of Clostridium difficile (C diff) colitis be suspected?