The American Society of Colon and Rectal Surgeons clinical practice guideline focuses on the evaluation, management, and prevention of CDI. This article discusses the key recommendation from the guideline.

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CDI in India

The rates of Clostridioides difficile or Clostridium difficile infection (CDI) has increased in the last few decades, and this has made it a global health challenge. The rise in recurrent and resistant infections of CDI has particularly resulted in increased morbidity and mortality.

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Evaluation of CDI

When CDI is suspected, a disease-specific history should be performed emphasising risk factors, symptoms, underlying comorbidities, and signs of severe or fulminant disease.

When assessing CDI, it is imperative to correlate the risk factors along with the symptoms observed. CDI testing should be avoided in patients who do not show the characteristic symptoms of C difficile diarrhoea such as unexplained watery stools 3 or more times a day without intervening constipation or formed bowel movements.

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Severity evaluation

Patients should be evaluated to determine the severity of CDI and for the presence of peritonitis or multisystem organ failure.

The clinical presentation of CDI may vary from severe, fulminant, life-threatening infection to mild CDI or asymptomatic carrier state. However, the system for classifying CDI into mild/nonsevere, severe, or severe-complicated/fulminant is not well defined.

1. Mild CDI - Diarrhoea, leukocytosis (but less than 15 × 103/µL), and abdominal pain with positive testing for C difficile in the absence of hypotension or organ failure such as kidney injury.
2. Severe CDI - Elevated creatinine or leukocytosis over 15 × 103/µL.
3. Severe-complicated or fulminant CDI - Peritonitis, worsening abdominal pain and distension, sepsis, otherwise unexplained clinical deterioration, ileus or megacolon, and/or organ failure.

Multisystem organ failure is a strong predictor of postoperative mortality following emergency colectomy for C difficile colitis. Due to the increased mortality rates from severe CDI, stool studies should be conducted to expedite the diagnosis.

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Diagnosis

The diagnosis of CDI should include laboratory stool testing, and 2-step testing should be utilised to increase accuracy.

Laboratory stool testing is the most accurate method to diagnose CDI. Only watery or loose stool samples (not swabs or formed stool) should be tested.

2-step testing is recommended for testing CDI as single tests may lack the sensitivity and specificity to accurately distinguish between an asymptomatic carrier and symptomatic CDI. 2-step testing is done using 2 enzyme immunoassays highly sensitive for glutamate dehydrogenase (GDH) and highly specific for C difficile toxins.

These assays have high specificity and sensitivity (> 90%) and are quick and inexpensive. Nucleic acid amplification testing (NAAT) is an alternative to GDH-based testing.

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Endoscopic evaluation

Routine endoscopic evaluation to diagnose or determine the extent of CDI is not recommended.

Routine endoscopic for diagnosing CDI is not recommended due to limited clinical utility and lack of validated predictive value in guiding therapy or providing prognostic information. Endoscopy is also associated with the risk of perforation.

In CDI evaluation, endoscopy is reserved only for cases in which concomitant conditions confound the diagnosis or when an urgent diagnosis is required.

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Radiologic evaluation

Radiologic evaluation has limited utility in the setting of CDI.

Just like endoscopy, a radiographic investigation has limited utility in CDI. CT scan has a low predictive value in assessing disease severity and the need for surgical intervention. It is reported that around 40% of patients with CDI have a normal CT scan without radiographic evidence of colitis.

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Medical management of CDI

1. Infection control measures should be implemented for hospitalised patients with CDI.

1. C difficile can spread rapidly in a hospital setting. Hence, effective measures to prevent disease containment and transmission are necessary.
2. Combining contact precautions and handwashing with soap and water is recommended to prevent transmission of CDI in hospital and long-term care facilities.

2. Implementing an evidence-based antibiotic stewardship program can decrease rates of CDI.

1. Overuse and inappropriate use of antibiotics is a well-known risk factor for CDI. It is recommended to stop associated antibiotics once CDI has been diagnosed, as clinically indicated, and extend the use of anti-C difficile treatment beyond the duration of other antibiotics for 5 to 14 days.
2. Oral vancomycin or fidaxomicin is considered first-line treatment for an initial CDI, whereas metronidazole alone is no longer considered an appropriate first-line treatment.
3. Fidaxomicin has been shown to have fewer CDI recurrences and higher success rates treating CDI than vancomycin. For non-fulminant CDI, the recommended oral vancomycin dose is 125 mg 4 times a day and the recommended fidaxomicin dose is 200 mg twice a day; a 10-day course of either medication resolves CDI diarrhoea in >90% of patients.

3. Probiotics may be useful in preventing CDI, but not in treating CDI.

The use of probiotics in CDI is safe and tolerable, however, there is a lack of clear evidence for the studies supporting the use of probiotics in primary treatment and prevention.

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Surgical therapy for CDI

Surgery for C difficile colitis should typically be reserved for patients with colonic perforation or severe colitis who do not improve with medical therapy.

Surgery is an important part of CDI management. Around 30% of patients with severe-complicated or fulminant CDI and 1% of all patients with CDI require surgery. Colonic perforation is the main indication for surgery. Apart from this, IBD is a significant risk factor for developing CDI and for requiring surgery. Subtotal colectomy with end ileostomy is typically the operative procedure recommended for severe-complicated or fulminant C difficile colitis.

A diverting loop ileostomy with antegrade colonic lavage may be an alternative to subtotal colectomy for the treatment of severe-complicated or fulminant CDI.

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Recurrent and refractory CDI

A prolonged course of vancomycin, adding bezlotoxumab or using fidaxomicin, is an acceptable therapy for recurrent or refractory CDI in stable patients. Patients with recurrent or refractory CDI should typically be considered for faecal bacteriotherapy (eg, intestinal microbiota transplantation) if conventional measures, including appropriate antibiotic treatment, have failed.

In situations where conventional antibiotic therapy for recurrent CDI fails, other antimicrobials can be considered. Adjunctive agents including other antimicrobials, binding agents, and probiotics may be considered in addition to standard treatment in cases of recurrent or refractory CDI.

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