10
Treatment
Table 2. Recommendations for the Treatment of
Clostridioides difficile Infection (CDI) in Adults
Clinical
presentation Recommended and Alternative Treatments
Initial CDI episode Preferred: Fidaxomicin 200 mg given twice daily for 10 days
Alternative: Vancomycin 125 mg given 4 times daily by mouth
for 10 days
Alternative for nonsevere CDI, if above agents are unavailable:
Metronidazole, 500 mg 3 times daily by mouth for 10–14 days
First CDI
recurrence
Preferred: Fidaxomicin 200 mg given twice daily for 10 days,
OR twice daily for 5 days followed by once every other day for
20 days
Alternative: Vancomycin by mouth in a tapered and pulsed
regimen
Alternative: Vancomycin 125 mg given 4 times daily by mouth
for 10 days
Adjunctive treatment: Bezlotoxumab 10 mg/kg given
intravenously once during administration of SOC antibiotics
a
Second or
subsequent CDI
recurrence
Fidaxomicin 200 mg given twice daily for 10 days, OR twice
daily for 5 days followed by once every other day for 20 days
Vancomycin by mouth in a tapered and pulsed regimen
Vancomycin 125 mg 4 times daily by mouth for 10 days
followed by rifaximin 400 mg 3 times daily for 20 days
Fecal microbiota transplantation
Adjunctive treatment: Bezlotoxumab 10 mg/kg given
intravenously once during administration of SOC antibiotics
a
Fulminant CDI Vancomycin 500 mg 4 times daily 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
e recommendations are based the 2017 guidelines and the 2021 focused guideline update.
Abbreviations: CDI, Clostridioides difficile infection; SOC, standard of care.
a
Bezlotoxumab may also be considered for patients with other risks for CDI recurrence but
implementation depends upon available resources and logistics for intravenous administration,
particularly for those with an initial CDI episode. Additional risk factors for CDI recurrence
include age >65 years, immunocompromised host (per history or use of immunosuppressive
therapy), and severe CDI on presentation.
b
e 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."
