In this episode, I’ll discuss the recent updates to the IDSA and ACG C diff guidelines.
The American College of Gastroenterology published an update to their C Diff guidelines in May of 2021, and The Infectious Disease Society of American published a focused update to their guidelines in June of 2021.
While the ACG guidelines were comprehensive in nature, the IDSA guidelines only focused on a few questions.
The IDSA guidelines are far more prescriptive in their recommendations than the ACG guidelines. The IDSA makes actual recommendations for use while the ACG makes liberal use of the word “consider” in their recommendations.
For the first episode of C Diff IDSA recommends:
…using fidaxomicin rather than a standard course of vancomycin (conditional recommendation, moderate certainty of evidence)…
vs ACG which for the first episode of C Diff recommends:
…oral vancomycin…(strong recommendation, low quality of evidence)… OR …oral fidaxomicin…(strong recommendation, moderate quality of evidence)… OR …Oral metronidazole…for treatment of an initial nonsevere CDI in low-risk patients (strong recommendation/ moderate quality of evidence)…
For recurrent episodes of C Diff the IDSA recommends:
…In patients with recurrent CDI episodes, we suggest fidaxomicin (standard or extended pulsed regimen) rather than a standard course of vancomycin (conditional recommendation, low certainty evidence)…
For recurrent episodes of C Diff the ACG recommends:
…We suggest tapering/pulsed-dose vancomycin for patients experiencing a first recurrence after an initial course of fidaxomicin, vancomycin, or metronidazole (strong recommendation, very low quality of evidence)…We recommend fidaxomicin for patients experiencing a first recurrence after an initial course
of vancomycin or metronidazole (strong recommendation, moderate quality of evidence)…
The glaring difference between these two expert guidelines is that the IDSA is overtly recommending fidaxomicin first line, while the ACG is placing fidaxomicin along side vancomycin as a potential option for use.
What “stinks” is that the IDSA recommendations were known to be supporting fidaxomicin first as early as October 2020:
Wow. Good job following the evidence. Fidaxomicin preferred over vancomycin for initial CDI episode in next CDI guidelines. #IDWeek2020 pic.twitter.com/YZF08TnnjF
— Jason Gallagher (@JGPharmD) October 23, 2020
Surely the ACG knew of this information prior to guideline publication, yet this discrepancy is not addressed anywhere within the guidelines or by an accompanying editorial. The closest that ACG comes to addressing this is in a podcast interview of one of the authors. At about the 16:45 mark of this podcast, the guideline author states that they looked at the evidence of fidaxomicin and felt it’s benefits over vancomycin were not big enough to place it first line over vancomcyin.
Presumably, the ACG and the IDSA experts looked at the same evidence but came to different conclusions. This puts frontline clinicians in the situation of having to choose which expert guideline to follow, even though they were both published at the same time.
Let me know in the comment section how you are planning to handle this conflict between guidelines at your institution.
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One issue will be the cost of Fidaxomicin. All insurances will likely require a prior auth, with some wanting the C diff sample typed (as the benefit of decreased C diff recurrence isn’t seen with the NAP-1 strain). I think pulse dose Vancomycin is underused and would be a good alternative if the patient is unable to obtain Fidaxomicin.
Overall, at my institution we use Vancomycin for first use, and only use Metronidazole if patient is unable to obtain PO Vanc. Fidaxomicin for recurrent C diff, and only use another course of Vanc or pulse dose Vanc in patient is unable to obtain Fidaxomicin.