Note: This CDS artifact's Status has been temporarily changed from 'Active' to 'Draft' pending annual review
|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 (firstname.lastname@example.org) for additional information.
Artifact Creation and Usage
|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|
|Infectious Disease Society of America (IDSA) recommendations are copyrighted by the IDSA; the AHRQ EPC report (See references) is copyrighted by AHRQ|
Please note: CQL artifact is L3 experimental.
Semi-structured text that describes the recommendations for implementation in CDS
|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.|
|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)|
|Intended for use by providers delivering care in an inpatient setting|
|Published evidence; AHRQ EPC Report|
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.
|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
|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.|
|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.|
|vancomycin, oral: strong
vancomycin, rectal: weak
metronidazole, intravenous: strong
|vancomycin, oral: moderate
vancomycin, rectal: low
metronidazole, intravenous: moderate
|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.|
|vancomycin, oral: weak
vancomycin, tapered and pulsed regimen: weak
|vancomycin, oral: low
vancomycin, tapered and pulsed regimen: low
|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.|
|vancomycin, tapered and pulsed: weak
vancomycin followed by rifaximin: weak
Fecal microbiota transplantation: strong
|vancomycin, tapered and pulsed: low
vancomycin followed by rifaximin: low
Fecal microbiota transplantation: moderate
|(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)|
See the clinical pathway in the Technical File section of this artifact
This treatment pathway is actively used by clinicians in the University of Pennsylvania Health System.