2017 C Difficile Guidelines Focus on New Treatment Options

The updated C difficile infection guidelines allow for more efficient diagnosis and better therapeutic interventions, especially in recurrent cases, according to a recent review.

Researchers from the University of Leeds reviewed and compared the 2010 and 2017 Infectious Disease Society of America guidelines for the diagnosis and treatment of C difficile infection in order to highlight the key changes. The study authors wrote that C difficile infection continues to threaten healthcare institutions and, when it’s a community-associated infection, it is most strongly associated with antibiotic exposure.

The terminology used for C difficile infection severity changed between 2010 and 2017, the study authors noted. “Moderate” cases have now become “non-severe” while those labeled “severe/complicated” are now termed “fulminant.”

The most prominent changes to the new guidelines include the removal of metronidazole as a first-line therapy for C difficile infection as well as the addition of fidaxomicin as an alternative for treatment with vancomycin in either non-severe or severe cases of infection. While both fidaxomicin and vancomycin have similar initial clinical cure rates, fidaxomicin is the superior therapy, they said.

In the past, metronidazole was the treatment most often prescribed, but now new data shows that it is clearly “inferior to vancomycin,” the reviewers said.

Another key point in the new guidelines states that fecal microbiota transplant is now a recommended treatment option in patients who have experienced 3 or more recurrences of C difficile infection. The guidelines do not discuss the relative unknowns regarding the long-term safety related to the transfer of the gut microbe of one individual to another, the authors wrote. Additionally, unanswered questions remain about the optimal dose and formula, delivery pathway, and the use of autologous compared to donor feces.

When the guidelines were published, there was a 2016 cutoff date for all research considered. Therefore, the study authors said, the guidelines do not include information about the relatively new therapeutic options—bezlotoxumab and extended fidaxomicin.

The new guidelines also contain new pediatric recommendations. It is likely that infants can carry toxigenic strains of C difficile asymptomatically, therefore testing for the infection should not be routinely recommended for children under 12 months of age who experience diarrhea.

Finally, the study authors said, there is a growing emphasis placed on the importance of using a toxin test as part of a laboratory diagnosis confirmation in C difficile infections. Using nucleic acid amplification tests (NAATs, or PCR testing) has become commonplace for C difficile testing, but not in all settings, such as in Europe. The study authors said that NAATs are responsible for the over-diagnosis of C difficile and poor accuracy in C difficile testing has led to implications such as unnecessary treatment, isolation, and labels/stigma for the patients. All of these factors could influence patients’ future medical management down the road, the study authors said.

“The updated IDSA/SHEA guidelines contain some key changes compared with the 2010 version, reflecting the improved evidence base for the optimal diagnosis and treatment of C difficile infection,” the study authors summarized.

The paper, “Comparison of the 2010 and 2017 Infectious Diseases Society of America guidelines on the diagnosis and treatment of Clostridium difficile infection,” was published in Current Opinion in Gastroenterology.