Suspected C. difficile Infection
≥3 unformed stools in 24h + risk factors (antibiotics, hospitalization)
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GastroenterologyManagement
C. difficile Infection Management (IDSA/SHEA 2021)
C. difficile Infection Management (IDSA/SHEA 2021): Suspected C. difficile Infection → Confirm Diagnosis → Initial Management → Assess Severity → Non-Se...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action Confirm Diagnosis
Test only diarrheal stool (liquid/take shape of container)
- NAAT (PCR) alone OR
- GDH + toxin EIA (two-step) OR
- NAAT + toxin EIA
- Do NOT test for cure
- Do NOT test asymptomatic patients
03Action Initial Management
Start while awaiting results if high suspicion
- STOP inciting antibiotic if possible
- Contact precautions
- Avoid antidiarrheals
- Avoid PPIs if not strictly indicated
04Decision Assess Severity
Classify as non-severe, severe, or fulminant
- Non-Severe
05Action Non-Severe CDI
WBC ≤15,000 AND Cr <1.5
- Fidaxomicin 200mg PO BID x 10 days (preferred)
- OR Vancomycin 125mg PO QID x 10 days
- Avoid metronidazole in adults
06Decision High Recurrence Risk?
Age ≥65, immunocompromised, severe episode, previous CDI
- High Risk
07Action Consider Bezlotoxumab
Anti-toxin B monoclonal antibody
- Single IV dose during antibiotic treatment
- Reduces recurrence by ~40%
- High-risk patients: age ≥65, immunocompromised, severe CDI, prior CDI
08Outcome CDI Resolved
Resolution = formed stools + no new diarrhea
- Recurs
09Action First Recurrence
10-25% of patients recur
- Fidaxomicin 200mg BID x 10 days (preferred over vanco)
- OR Vancomycin taper:
- 125mg QID x 10-14d, then
- 125mg BID x 7d, then
- 125mg daily x 7d, then
- 125mg q2-3 days x 2-8 weeks
- Consider FMT after
- Recurs again
10Action Second or More Recurrence
FMT strongly recommended
- FMT after standard course of vancomycin (preferred)
- FMT success rate 80-90%
- If FMT not available: extended vancomycin taper + rifaximin
- Fidaxomicin extended dosing (every other day weeks 2-4)
- Path rejoins step 08Shared downstream outcome
11Outcome Prevention Measures
Antibiotic stewardship, hand hygiene, probiotics (limited evidence)
- Resolves
- Path rejoins step 08Shared downstream outcome
- Severe
12Action Severe CDI
WBC ≥15,000 OR Cr ≥1.5 OR age ≥65 with severe illness
- Fidaxomicin 200mg PO BID x 10 days (preferred)
- OR Vancomycin 125mg PO QID x 10 days
- Consider vancomycin + IV metronidazole if critically ill
- Path rejoins step 06Shared downstream outcome
- Fulminant
13Warning ⚠️ Fulminant CDI
Hypotension, shock, ileus, or megacolon
- Vancomycin 500mg PO/NG QID
- + Metronidazole 500mg IV q8h
- + Vancomycin enemas 500mg/100mL NS q6h if ileus
- Surgical consult STAT
- Consider colectomy
14Warning Surgical Evaluation
For fulminant CDI refractory to medical therapy
- Lactate >5, WBC >50,000
- Toxic megacolon (colon >6cm)
- Peritonitis, perforation
- Subtotal colectomy with end ileostomy
- OR Loop ileostomy with colonic lavage (may preserve colon)
- Path rejoins step 08Shared downstream outcome
Guideline Source
IDSA/SHEA Clinical Practice Guidelines for CDI in Adults: 2021 Update
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- FMT availability varies by institution
- Bezlotoxumab availability and cost
- Severity criteria may evolve
- Vancomycin taper schedules vary
- Surgery decisions require multidisciplinary input
Applicable Regions
USGlobal
EU: ESCMID guidelines are similar
US: IDSA/SHEA 2021 is current standard
Version 1Next review: 2027-01-01
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Related Resources
Frequently Asked Questions
What is the C. difficile Infection Management (IDSA/SHEA 2021)?
The C. difficile Infection Management (IDSA/SHEA 2021) is a management clinical algorithm for Gastroenterology. It provides a structured decision tree to guide clinical decision-making, based on IDSA/SHEA Clinical Practice Guidelines for CDI in Adults: 2021 Update.
What guideline is the C. difficile Infection Management (IDSA/SHEA 2021) based on?
This algorithm is based on IDSA/SHEA Clinical Practice Guidelines for CDI in Adults: 2021 Update (DOI: 10.1093/cid/ciab549).
What are the limitations of the C. difficile Infection Management (IDSA/SHEA 2021)?
Known limitations include: FMT availability varies by institution; Bezlotoxumab availability and cost; Severity criteria may evolve; Vancomycin taper schedules vary; Surgery decisions require multidisciplinary input. Individual patient factors may require deviation from these recommendations.
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