Clostridioides (Clostridium) difficile Infection



Any patient taking antibiotics!

  • Especially those at risk of antibiotic associated diarrhea and C. difficile due to their current antibiotic regimen or their past history.
  • May be more effective with higher baseline incidence of C. difficile (>5%) and higher risk (ie. multiple C. difficile recurrences or taking 2 or more antibiotics).
  • Low quality or weak evidence for using probiotics as an adjunctive therapy for treating C. difficile.
  • No consensus in the literature on strain, strength, or dose.
  • Commonly used species with individual evidence include:
    • Lactobacillus rhamnosus GG (most evidence)
    • Lactobacillus casei
    • Lactobacillus acidophilus
    • Kefir (Expert opinion, 1 cup BID-TID, avoid in diabetics)
    • Saccharomyces boulardii
    • Mixed strain formulations (often proprietary blends)

Pooled results of different strains still show benefit, indicating that positive effect may be seen regardless of strain.

  • Neutropenic patients
  • Patients under the age of 18 (for the purposes of these guidelines)
  • Patients admitted to the ICU


  • Studies indicate that initiating probiotics as close to the first dose of antibiotic therapy as possible is most effective.
  • Separating the dose from antibiotic dosing is not generally required.

Duration of therapy (no strong consensus):

  • Options include:
    • Fixed 14 day course
    • For the duration of antibiotic exposure
    • For the duration of antibiotic exposure and up to 7 days following completion


  • Single strain: some trials indicate at least 5 billion CFU (colony-forming units) per day. Others say at least 15 billion CFU.
  • Multi-strain: some suggestion that 50 billion CFU daily is best, depending on blend.