Clostridoides Difficile (C. diff) Infection (CDI) Treatment Pathway

Description
This evidence-based clinical pathway outlines treatment recommendations for initial Clostridoides difficile infection (CDI), including non-severe and fulminant, and recurrent CDI.

Developed by the ECRI Institute and the Penn Medicine Center for Evidence-based Practice (CEP) in collaboration with the Penn Medicine Antimicrobial Stewardship Program, Penn Value Improvement, Pharmacy, Nursing, Quality, and Information Services.

Contact: Emilia J. Flores (emilia.flores@pennmedicine.upenn.edu) for additional information.

 

Artifact Type
Creation Date
Version
1.1
Unique Identifier
CEP2097
Status
Experimental
False

Artifact Creation and Usage

Contributors
Keith Hamilton MD; David Pegues, MD; Brendan Kelly, MD, MS; Leigh Kennedy, DO; Naasha Talati, MD, MSCR; Amanda Binkley, PharmD, AAHIVP;  Lauren Dutcher, MD; Jennifer Braun, MHA, BSN, RN; Mary Coniglio, MBA, CPHQ; Colleen Mallozzi, MBA, BSN, RN, BSIS; Kristen Maloney, MSN, RN, AOCNS; Emilia Flores, PhD, RN; Nikhil Mull, MD; J. Jane Jue, MD, M.Sc; Gina Giradi, MS; Karen Schoelles, MD, SM; Craig Umscheid, MD, MSCE

 

 

IP Attestation The author asserts that this artifact has been developed in compliance with the intellectual property rights attributed to the source material.
Copyrights
Infectious Disease Society of America (IDSA) recommendations are copyrighted by the IDSA; the AHRQ EPC report (See references) is copyrighted by AHRQ
Implementation Details
Repository Information
Approval Date
Publication Date
Last Review Date
Knowledge Level

Semi-structured text that describes the recommendations for implementation in CDS

Purpose and Usage
Purpose
Presents Clostridioides difficile infection (CDI) therapy recommendations to facilitate treatment for initial, recurrent, and fulminant CDI episodes. Includes consult, imaging, and monitoring and follow-up recommendations. 
Intended Population
Adults patients in the acute care setting who have a positive CDI test and signs and symptoms of CDI or high clinical suspicion (e.g. temperature > 101.3F, high white blood count, >= three documented liquid stools in 24-hours)
Usage
Intended for use by providers delivering care in an inpatient setting
Supporting Evidence
Source Description
Published evidence; AHRQ EPC Report
References

Butler M, Olson A, Drekonja D, et al. Early Diagnosis, Prevention, and Treatment of Clostridium difficile: Update [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Mar. (Comparative Effectiveness Reviews, No. 172.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK361173; eith

Hamilton, MD; David Pegues, MD; Shawn Binkley, PharmD; Steven Morgan, PharmD; Daniel Timko, PharmD; Stephen Gluckman, MD. Antimicrobial Stewardship Gastroenteritis Clostridium difficile Associated Diarrhea Guidelines.Penn Medicine; 2018 Apr. 

McDonald, L. Clifford, Dale N. Gerding, Stuart Johnson, Johan S. Bakken, Karen C. Carroll, Susan E. Coffin, Erik R. Dubberke 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 66, no. 7 (2018): e1-e48.

Recommendation
IDSA recommendation for initial episode, non-severe:
vancomycin, 125 mg given 4 times daily for 10 days; fidaxomicin 200 mg given twice daily for 10 days; Alternate if above agents are unavailable: metronidazole, 500 mg 3 times per day by mouth for 10 days
Strength of Recommendation
vancomycin: strong
fidaxomicin: strong
metronidazole: weak
Quality of Evidence
vancomycin: high
fidaxomicin: high
metronidazole: high
Recommendation
IDSA recommendation for initial episode, severe: vancomycin, 125 mg given 4 times daily for 10 days; fidaxomicin 200 mg given twice daily for 10 days.
Strength of Recommendation
vancomycin: strong
fidaxomicin: strong
Quality of Evidence
vancomycin: high
fidaxomicin: high
Recommendation
IDSA recommendation for initial episode, fulminant:  vancomycin 500 mg 4 times per day by mouth or by nasogastric tube. If ileus, consider adding rectal instillation of vancomycin. Intravenously administered metronidazole (500 mg every 8 hours) should be administered together with oral or rectal vancomycin, particularly if ileus is present.
Strength of Recommendation
vancomycin, oral: strong
vancomycin, rectal: weak
metronidazole, intravenous: strong
Quality of Evidence
vancomycin, oral: moderate
vancomycin, rectal: low
metronidazole, intravenous: moderate 
Recommendation
IDSA recommendation for first recurrence: vancomycin 125 mg given 4 times daily for 10 days if metronidazole was used for the initial episode; use a prolonged tapered and pulsed vancomycin regimen if a standard regimen was used for the initial episode (e.g., 125 mg 4 times per day for 10–14 days, 2 times per day for a week, once per day for a week, and then every 2 or 3 days for 2–8 weeks), or fidaxomicin 200 mg given twice daily for 10 days if vancomycin was used for the initial episode.
Strength of Recommendation
vancomycin, oral: weak
vancomycin, tapered and pulsed regimen: weak
fidaxomicin: weak
Quality of Evidence
vancomycin, oral: low
vancomycin, tapered and pulsed regimen: low
fidaxomicin: moderate
Recommendation
IDSA recommendation for second or subsequent recurrence: VAN in a tapered and pulsed regimen; VAN, 125 mg 4 times per day by mouth for 10 days followed by rifaximin 400 mg 3 times daily for 20 days; FDX 200 mg given twice daily for 10 days; OR Fecal microbiota transplantation.
Strength of Recommendation
vancomycin, tapered and pulsed: weak
vancomycin followed by rifaximin: weak
fidaxomicin: weak
Fecal microbiota transplantation: strong
Quality of Evidence
vancomycin, tapered and pulsed: low
vancomycin followed by rifaximin: low
fidaxomicin: low
Fecal microbiota transplantation: moderate
Artifact Representation
Inclusions
(positive CDI test AND (signs and symptoms of CDI) OR high clinical suspicion (e.g. temperature > 101.3F, high white blood count, >= three documented liquid stools in 24-hours)
Exclusions

N/A

Interventions and Actions

See the clinical pathway in the Technical File section of this artifact

Testing Experience
Pilot Experience

This treatment pathway is actively used by clinicians in the University of Pennsylvania Health System.