Leading groups update guidelines for C. difficile

New guidelines focus on diagnosis, infection prevention, and more

In 2018, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) released updated guidelines on management of Clostridium difficile infections in adults and children. The guidelines focus on diagnosis, revised initial treatment considerations, and infection prevention and control strategies for these patient populations.

C. difficile infections have risen in the last 10 years, and these infections have a substantial impact on health care costs. An estimated 500,000 C. difficile infections occur annually in the United States. The incidence is highest in older adults (≥65 y) and is higher in females and whites.

The IDSA/SHEA guidelines recommend that adult patients with unexplained and new-onset diarrhea (≥3 unformed stools in a 24-h period) should be tested for C. difficile infection. Different diagnostic tests are listed, such as use of a stool toxin test as part of a multistep algorithm. For children, testing is recommended for those who are aged 2 years or older and have prolonged or worsening diarrhea and risk factors or relevant exposure.

When treatment is initiated, the offending antibiotic should be discontinued immediately. For adults, either vancomycin (125 mg four times daily) or fidaxomicin ([Dificid]—Merck] 200 mg twice daily) for 10 days is recommended over metronidazole. Use of metronidazole should only be considered when patients have a nonsevere infection and if there is limited access to the recommended agents. Pharmacists should be aware of the recommended treatment options in the revised guidelines, as metronidazole is no longer recommended as an initial treatment option for adult patients with C. difficile infections. Also, pharmacists should be well versed in C. difficile prevention and control strategies and antibiotic stewardship programs at their institution.

For fulminant C. difficile infections, vancomycin 500 mg four times daily is the agent of choice, and I.V. metronidazole should be given in addition to vancomycin.

For children, metronidazole or vancomycin is recommended as initial treatment options for nonsevere C. difficile infections. If children have a severe infection, vancomycin is recommended over metronidazole. The guidelines also include specific recommendations for recurrent infections in adults and children.

Other recommendations include isolating patients with C. difficile infections in private rooms with use of their own toilets, having health care staff use proper precautions (i.e., gloves, gowns) when entering the patient’s room, and ensuring proper hand hygiene among staff before and after contact with infected patients. Patients should also be encouraged to wash their hands and shower to reduce the burden of spores on their skin.

The importance of antibiotic stewardship is also emphasized, and the guidelines note that there is insufficient evidence to recommend use of probiotics for primary prevention.

Risk factors for C. difficile colonization and infection include recent exposure to antibiotics, recent surgery (e.g., gastrointestinal procedures), and recent hospitalization. Therefore, effective prevention and management of these infections is essential to reduce the burden of disease.  

For the full article, please visit www.pharmacytoday.org for the June 2018 issue of Pharmacy Today.