In this episode, I’ll discuss the updated 2018 C. difficile guidelines.
The Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) have recently updated their joint guidelines for Clostridium difficile Infection.
The guidelines are labeled a 2017 update but were not published until recently in 2018. The previous guidelines were published in 2010.
There are several significant changes to the guidelines that pharmacists who care for patients with C. diff should be aware of:
Metronidazole is no longer recommended as monotherapy for C. diff. The guidelines now state:
Either vancomycin or fidaxomicin is recommended over metronidazole for an initial episode of CDI. The dosage is vancomycin 125 mg orally 4 times per day or fidaxomicin 200 mg twice daily for 10 days (strong recommendation, high quality of evidence).
This is a departure from the past 30 years when metronidazole and oral vancomycin were the main antibiotic agents used in the treatment of CDI.
Enough trials and retrospective reviews have concluded that metronidazole is inferior to vancomycin for treatment response or clinical cure in multiple settings, including hospitalized patients with mild to moderate C. diff.
In addition to mild to moderate disease, vancomycin and fidaxomycin now have an equal weighting for the treatment of severe C. diff.
The method of identifying the severity of C. diff infection has also changed slightly.
Leukocytosis >/=15,000 or a serum creatinine >1.5 mg/dL denote severe C. diff. The percentage change from baseline of serum creatinine was removed because a baseline is not always available.
Previously, the criteria to judge whether C. diff infection was severe were based on expert opinion. But now the database of the recent phase 3 fidaxomicin vs vancomycin treatment trials has been used to develop and validate criteria that might predict treatment failure or cure. Although the exact criteria listed in the guidelines is not the same as what was validated in the study, the authors state:
As a practical measure, we continue to recommend WBC count and serum creatinine as supportive clinical data for the diagnosis of severe CDI…
The term “severe complicated” is no longer used to describe the sickest group of patients with C. diff. Instead, patients with C. diff and hypotension, shock, or ileus are now said to have “fulminant C. diff.”
Treatment of fulminant C. diff continues to involve Vancomycin 500 mg 4 times per day by mouth or by nasogastric tube PLUS IV metronidazole 500 mg q8h. Be aware of the concern that oral vancomycin may not reach the bowel if an ileus is present. If ileus is present or suspected, the guidelines recommend adding vancomycin 500 mg in approximately 100 mL normal saline per rectum every 6 hours as a retention enema.
When treating a patient with oral and rectal vancomycin who has fulminant C. diff, it is reasonable to check at least one vancomycin serum level. Although vancomycin is not absorbed enterally, there are reports of patients with fulminant C. diff experiencing absorption and having potentially significant serum vancomycin concentrations.
Members of my Hospital Pharmacy Academy have access to a detailed training on C. diff, including pearls on treatment and prevention strategies. To learn more, go to pharmacyjoe.com/Academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
For recurrent c.diff, is fidamoxicin given preference over vanco? And for hospitals that do not have dificid on formulary, is it advisable to add due to updated guidelines?
The guidelines do not give preference over vanco for either first recurrence or second or subsequent recurrence.
We have no plans at this time to change fidaxomicin status (currently on formulary restricted to ID only and they rarely if ever use it).