Adult Guidelines
Clostridioides difficile Infection (CDI) (Outpatient)

Clostridioides difficile Infection (CDI) (Outpatient)

Clostridioides difficile Infection (CDI)

Ranges from watery diarrhea with lower abdominal pain, cramping, and nausea (with or without fevers and leukocytosis) to severe or fulminant colitis

Clostridioides difficile Infection (CDI)

  • ≥3 unformed stools in a 24 hour period without an alternative explanation, AND
  • Positive stool test for C. difficile

Severe CDI

  • WBC ≥15,000 cells/mL, AND/OR
  • Serum creatinine ≥1.5 mg/dL associated with CDI
  • Hospital admission should be considered; however, treatment is typically similar to non-severe CDI
    • Patients with severe disease may have ileus without stool output; these patients generally have colitis on imaging, abdominal pain/distention, and systemic illness - hospital admission recommended as this is considered fulminant

Recurrent CDI

  • CDI episode within 8 weeks of completion of therapy for previous CDI episode

Fulminant CDI

  • Hypotension or ileus
  • Intestinal perforation
  • Toxic megacolon
  • Hospital admission necessary for fulminant disease

Diagnosis & Evaluation

Initial testing recommendations

  • Do not test formed stool samples
  • Confirm patient has not received a laxative in the previous 48 hours
  • Do not test infants <1 year of age
  • Do not repeat testing within 7 days

Recurrent testing recommendations

  • 30% of patients have recurrent CDI within 30 days of treatment
  • Retest to confirm the diagnosis

Empiric Treatment

  • Discontinue antibiotics not used for CDI treatment whenever possible
    • If antibiotic therapy is still needed, select the narrowest agent possible and avoid agents with strong association with CDI (i.e. fluoroquinolones, clindamycin, 3rd and 4th generation cephalosporins, and carbapenems)
  • Discontinue gastric acid suppression medications whenever possible, especially PPIs
  • Discontinue laxatives
  • Do not prescribe anti-motility agents
  • Probiotics are not recommended to treat or prevent CDI by ACG or IDSA/SHEA
  • CDI = ≥3 unformed stools in a 24-hour period without an alternative explanation, AND positive stool test for C. difficile
  • Severe = WBC ≥15,000 cells/mL and/or serum creatinine ≥1.5 mg/dL associated with CDI

CDI episode within 8 weeks of completion of therapy for previous CDI episode

CDI episode with associated hypotension, ileus, intestinal perforation, or toxic megacolon

Duration of Treatment

Additional Information

November 17, 2023

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