Updates in the Management of Clostridium Difficile for Adults

Kimberly E. Ng, PharmD, BCPS


US Pharmacist. 2019;44(4):HS9-HS12. 

In This Article


In February 2018, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) released an update in the clinical practice guidelines for CDI in adults and children, which included new recommendations.[4] The biggest change from the previous guideline involves the initial treatment of CDI.

Metronidazole is no longer recommended as first-line therapy for adults. Oral vancomycin and fidaxomicin are now supported as first-line options for both non-severe and severe initial episodes of CDI. This change stems from evidence that either option ensures resolution of symptoms and sustained resolution one month after treatment. Metronidazole is only recommended for nonsevere initial episodes when patients are unable to obtain or be treated with oral vancomycin or fidaxomicin. Repeated or prolonged treatment courses should be avoided owing to the risk of neurotoxicity. Patients with fulminant CDI should receive vancomycin 500 mg 4 times per day in combination with IV metronidazole. For recurrent CDI, metronidazole should not be used. If metronidazole was used for initial treatment, patients should receive oral vancomycin. If vancomycin was used as initial treatment, vancomycin can be administered again but as a tapered and pulsed regimen, or fidaxomicin can be used.

In second or subsequent recurrences, patients can be treated with oral vancomycin, fidaxomicin, or a fecal transplant. The guideline does not advise extending CDI treatment beyond the recommended treatment course nor does it recommend restarting CDI treatment empirically for a patient who requires continued antibiotic therapy. Table 1 presents the treatment recommendations from the updated 2018 guidelines.[4]