Recently, an updated clinical practice guideline for ‘Clostridium difficile infections’ (CDI) was published in an online journal called Clinical Infectious Diseases. Doing so, the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) shared updated guidelines for diagnosing and treating Clostridium difficile infections.
The wide-ranging clinical practice guideline talking about the epidemiology, diagnosis, treatment, and prevention of CDI was written by a multinational expert panel, which included physicians and was validated by the IDSA and SHEA.
The guideline, which is an update from the earlier 2010 IDSA/SHEA CDI recommendation, will serve as a very important resource to the medical, infection prevention, and public health communities. It also presents several unresolved aspects of CDI diagnosis, treatment, and prevention that highlight important potential research opportunities for the academic community.
Worldwide, CDI remains an urgent public health problem. In the United States alone, CDI is the most common healthcare-associated pathogen, with around half a million cases and more than 29,000 deaths attributable to C difficile each year.
The latest update by SHEA and IDSA has incorporated recommendations for children (this is after following the adult endorsements for epidemiology, diagnosis, and treatment), includes substantial changes in the supervision of this infection and reflects the evolving controversy over best methods for diagnosis. As physicians and healthcare unit staff you must be aware of the fact that, Clostridium difficile remains the most important cause of healthcare-associated diarrhea and has become the most commonly identified cause of healthcare-associated infection in adults in the United States. Additionally, C. difficile has recognized itself as an important community pathogen.
Although the occurrence of the epidemic and virulent ribotype 027 strain has declined noticeably along with overall CDI rates in parts of Europe, but it still remains one of the most commonly identified strains in the United States – where it is causing a sizable minority of CDIs, especially healthcare-associated CDIs.
In simple terms, the updated guidelines, eventually recommend epidemiology, diagnosis, treatment, infection prevention, and environmental management.
- Clifford McDonald, MD, co-chair of the guidelines panel and associate director for science in the Division of Healthcare Quality Promotion for the Centers for Disease Control and Prevention (CDC) opined that “We can better control this epidemic by learning how to use new treatments and diagnostics. The role of the infectious disease specialist is critical, not only in providing expert diagnosis and treatment of C. diff. infections, but also in helping set institutional policies that will lead to their prevention – including reducing the inappropriate use of antibiotics through good stewardship.”
Dr. McDonald further elaborates that, not everyone diagnosed with C. diff. requires treatment, “We often find people get better on their own if they stop taking the offending antibiotic.”
The new guidelines put forth by the SHEA and IDSA are:
- Fidaxomicin or Vancomycin – Antibiotics vancomycin or fidaxomicin should be used for initial treatment of even mild C. diff., rather than metronidazole. In the previous guidelines this was recommended as first-line therapy. Study shows the cure rates are higher for vancomycin and fidaxomicin than for metronidazole.
- Fecal Microbiota Transplantation (FMT) – The guidelines recommend FMT for treatment of people with two or more recurrences of C. diff. and for whom traditional antibiotic treatment has not worked.
FMT is a first-hand treatment since the last guidelines were published; however it is not approved by the Food and Drug Administration (FDA). Nevertheless, FDA has issued Guidance for Industry regarding the use of FMT to treat C. diff. infection not responsive to standard therapies
FMT involves transferring fecal bacteria from a healthy person’s stool to the gut of a person with recurrent C. diff., to replenish the good bacteria and control the disease-causing bacteria.
- Further the updated guidelines include the same suggestions for preventing the spread of C. diff. as the 2010 guidelines. This includes isolating infected patients and ensuring healthcare workers and visitors use gloves and gowns. Additionally, it also calls for increased attention to antibiotic stewardship to reduce the unwarranted use of the drugs.
- While nearly all antibiotics predispose people to C. diff., some are of particular concern, including the fluoroquinolones, cephalosporins and clindamycin.
- The guidelines make no recommendation for the use of probiotics.
- “We tell patients that for the most part they won’t hurt, but at this point we can’t make a recommendation for which ones to use and specifically how to use them,” concluded Dr. McDonald.
The new recommendations also include guidelines for epidemiologic surveillance, diagnosis, and treatment of C. diff. in children, which the 2010 guidelines did not address.