Recommendations for the Treatment of Clostridium difficile Infection in Adults

Clinical Definition

Supportive Clinical Data

Recommended Treatment^a

Strength of Recommendation/ Quality of Evidence

Initial episode, non-severe

Leukocytosis with a white blood cell count of ≤15,000 cells/mL and a serum creatinine level < 1.5 mg/dL

·         VAN 125 mg given 4 times daily for 10 days OR

·         FDX 200 mg given twice daily for 10 days

·         Alternate if above agents are unavailable: metronidazole 500 mg 3 times daily by mouth for 10 days

·         Strong/High

·         Strong/High

·         Weak/High

Initial episode, severe^b

Leukocytosis with a white blood cell count of ≥ 15,000 cells/mL or a serum creatinine level > 1.5 mg/dL

·         VAN 125 mg 4 times per day by mouth for 10 days OR

·         FDX 200 mg given twice daily for 10 days

·         Strong/High

·         Strong/High

Initial episode, fulminant

Hypotension or shock, ileus, megacolon

·         VAN 500 mg 4 times daily per day by mouth or by nasogastric tube. If ileus, consider adding rectal instillation of VAN. Intravenously administered metronidazole (500 mg every 8 hours) should be administered together with the oral or rectal VAN, particularly if ileus is present.

·         Strong/Moderate (oral VAN); Weak/Low (rectal VAN); Strong/Moderate (intravenous metronidazole)

First recurrence

…

·         VAN 125 mg given 4 times daily for 10 days if metronidazole was used for the initial episode OR

·         Use a prolonged tapered and pulsed VAN regimen if a standard regimen was used for the initial episode (eg 125 mg 4 times daily per day for 10-14 days, 2 times per day for a week, once per day for a week, and then every 2 or 3 days for 2-8 weeks) OR

·         FDX 200 mg given twice daily for 10 days if VAN was used for the initial episode

·         Weak/Low

·         Weak/Low

·         Weak/Moderate

Second or subsequent recurrence

…

·         VAN in a tapered and pulsed regimen OR

·         VAN 125 mg 4 times per day by mouth for 10 days followed by rifaxamin 400 mg 3 times daily for 20 days OR

·         FDX 200 mg given twice daily for 10 days OR

·         Fecal microbiota transplantation^c

·         Weak/Low

·         Weak/Low

·         Weak/Low

·         Strong/Moderate