Title: Update to C. Difficile Treatment

Keywords: clostridium difficile, antibiotics, vancomycin (PubMed Search)

Posted: 8/4/2018 by Ashley Martinelli (Updated: 3/4/2026)

IDSA/SHEA recently released a guideline update for the management of Clostridium difficle infections
Discontinue inciting antibiotic therapy as soon as possible
Metronidazole is no longer considered first line therapy for C. difficle infection
Treatment course for 10 days unless initial fulminant or recurrence requiring vancomycin taper
Remember: Vancomycin IV does not cross into the GI tract and cannot be used to treat C. difficile

Clinical Definition		Treatment
Initial episode, non-severe	WBC ≤ 15,000 AND SCr <1.5	Vancomycin PO 125mg 4x daily, OR Fidaxomicin PO 200mg 2x daily If above agents unavailable, metronidazole PO 500mg 3x daily
Initial episode, severe	WBC ≥ 15,000 OR SCr >1.5	Vancomycin PO 125mg 4x daily, OR Fidaxomicin PO 200mg 2x daily
Initial episode, fulminant	Hypotension, shock, ileus, megacolon	Vancomycin PO 500mg 4x daily Ileus? Give vancomycin enema 500mg q8h
First Recurrence		Prolonged vancomycin PO taper 125mg 4x daily, OR Vancomycin PO 125mg 4x daily x 10 days if metronidazole was used initially Consider fidaxomicin PO 200mg 2x daily if vancomycin used for initial treatment

References

McDonald LC, Gerding DN, Johnson S, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases. 2018;66(7):e1-e48.

PMID: 29562266