9
S, strong ; W, weak; C, conditional; H, high; M, moderate; L, low; VL, very low quality of evidence;
GP, good practice; NR, no recommendation
➤ For patients with a recurrent CDI episode within the last six months, we
suggest using bezlotoxumab as a co-intervention along with standard-
of-care (SOC) antibiotics rather than SOC antibiotics alone (C-VL).
Comment: This recommendation places a high value on potential clinical benefits,
but implementation is often limited by feasibility considerations. In settings where
logistics is not an issue, patients with a primary CDI episode and other risk factors
for CDI recurrence (such as age ≥65 years, immunocompromised host [per history
or use of immunosuppressive therapy], and severe CDI on presentation) may
particularly benefit from receiving bezlotoxumab. Data on the use of bezlotoxumab
when fidaxomicin is used as the SOC antibiotic are limited. The Food and Drug
Administration warns that "in patients with a history of congestive heart failure
(CHF), bezlotoxumab should be reserved for use when the benefit outweighs the risk."
➤ Fecal microbiota transplantation (FMT) is recommended for patients
with multiple recurrences of CDI who have failed appropriate antibiotic
treatments (S-M).
➤ There are insufficient data at this time to recommend extending
the length of anti-C. difficile treatment beyond the recommended
treatment course or re-starting an anti-C. difficile agent empirically
for patients who require continued antibiotic therapy directed against
the underlying infection or who require re-treatment with antibiotics
shortly after completion of CDI treatment, respectively (NR).
Pediatric
➤ Either metronidazole or vancomycin is recommended for the
treatment of children with an initial episode or first recurrence of
non-severe CDI (see Table 4 for dosing) (W-L).
➤ For children with an initial episode of severe CDI, oral vancomycin is
recommended over metronidazole (S-M).
➤ For children with a second or greater episode of recurrent CDI, oral
vancomycin is recommended over metronidazole (W-L).
➤ Consider fecal microbiota transplantation (FMT) for pediatric patients
with multiple recurrences of CDI following standard antibiotic
treatments (W-VL).
