UMEM Educational Pearls

Category: Infectious Disease

Title: Update to C. Difficile Treatment

Keywords: clostridium difficile, antibiotics, vancomycin (PubMed Search)

Posted: 8/4/2018 by Ashley Martinelli (Updated: 5/28/2023)
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  • IDSA/SHEA recently released a guideline update for the management of Clostridium difficle infections
  • Discontinue inciting antibiotic therapy as soon as possible
  • Metronidazole is no longer considered first line therapy for C. difficle infection
  • Treatment course for 10 days unless initial fulminant or recurrence requiring vancomycin taper
  • Remember: Vancomycin IV does not cross into the GI tract and cannot be used to treat C. difficile

Clinical Definition


Initial episode, non-severe

WBC ≤ 15,000 AND  SCr <1.5

  • Vancomycin PO 125mg 4x daily, OR
  • Fidaxomicin PO 200mg 2x daily

If above agents unavailable, metronidazole PO 500mg 3x daily


Initial episode, severe

WBC ≥ 15,000 OR  SCr >1.5

  • Vancomycin PO 125mg 4x daily, OR
  • Fidaxomicin PO 200mg 2x daily


Initial episode, fulminant

Hypotension, shock, ileus, megacolon

  • Vancomycin PO 500mg 4x daily
  • Ileus? Give vancomycin enema 500mg q8h


First Recurrence


  • Prolonged vancomycin PO taper 125mg 4x daily, OR
  • Vancomycin PO 125mg 4x daily x 10 days if metronidazole was used initially
  • Consider fidaxomicin PO 200mg 2x daily if vancomycin used for initial treatment



McDonald LC, Gerding DN, Johnson S, 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. 2018;66(7):e1-e48.

PMID: 29562266