Clostridioides difficile-Associated Diarrhea (CDAD)

Clinical Considerations

Management of all cases should include:

Discontinue inciting antibiotics, when possible.
Do not start new exacerbating antibiotics, when possible.
Avoid motility and antimotility agents, opioids, stool softeners, laxatives, and proton pump inhibitors.
Review hydration status.
For severe complicated disease consider Infectious Disease consultation.

Antibiotic Regimens

Indication for Therapy	Clinical Criteria	Antibiotic Regimens
Mild-to-moderate	WBC ≤15 SrCr <1.5 times baseline	vancomycin 125 mg PO^* q6h x 10-14 days
Mild-to-moderate	WBC ≤15 SrCr <1.5 times baseline	fidaxomicin‡ 200 mg PO q12h x 10 days
Severe, uncomplicated disease	WBC > 15 SrCr > 1.5 times baseline	vancomycin 125 mg PO^* q6h x 10-14 days
Severe, uncomplicated disease	WBC > 15 SrCr > 1.5 times baseline	fidaxomicin‡ 200 mg PO q12h x 10 days
Severe, complicated disease	WBC > 15 SrCr > 1.5 times baseline Hypotension or shock Ileus Toxic megacolon or perforation	vancomycin 125-500 mg PO/NG^* q6h +/- metroNIDAZOLE 500 mg IV q8h x 14 days, then reassess Note: if complete ileus, PR administration of vancomycin should be considered^†
Severe, complicated disease		fidaxomicin^‡ 200 mg PO q12h x 10 days +/- metroNIDAZOLE 500 mg IV q8h x 14 days, then reassess

^* Intravenous vancomycin is not effective for CDAD treatment.

^† PR dosing: Vancomycin 500 mg in 50 mL catheter tipped syringe, may add 50 mL NS PR after provision of vancomycin, clamp rectal tube for 3 hr (caution with toxic megacolon). Consider consulting general surgery.

^‡ fidaxomicin is restricted to ID

Treatment of Recurrent Disease

Consider Infectious Diseases consultation.
Prevent recurrent antimicrobial exposures.
Consider vancomycin pulse/taper regimen.
Consider referral for fecal microbiota transplantation (FMT). The closest centres are in Hamilton and Toronto.

References

Loo VG et al. Association of Medical Microbiology and Infectious Disease Canada treatment practice guidelines for Clostridium difficile infection. J Assoc Med Microbiol Infect Dis Canada. 2018;3(2):71-92.
Van Prehn J et al. European Society of Clinical Microbiology and Infectious Diseases: 2021 update on the treatment guidance document for Clostridioides difficile infection in adults. Clin Microbiol Infect. 2021;27 Suppl 2:S1-S21.
Cohen et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol. 2010:31:431-455.