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Chapter 1

C Diff Treatment Changes


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Tag GI

A few weeks ago, a post on Clay Smith’s Journal Feed about the new IDSA C diff guidelines caught my attention (specifically, that metronidazole is no longer recommended as first line therapy). Whuut? I tweeted this and @medquestioning tweeted back, “Need to dig to see why they dropped metro in the bucket.” Yes, @medquestioning, my thoughts exactly.

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New IDSA C Diff Guideline Treatment Recommendations


Initial Episode, Non Severe (WBC ≤ 15k, creatinine < 1.5)

First Line

  • Vancomycin 125 mg PO QID for 10 days
  • Fidaxomicin 200mg PO  BID for 10 days

Second line

  • Metronidazole 500mg TID PO for 10 days


Initial Episode, Severe (WBC >15k, creatinine >1.5)

  • Vancomycin 125 mg PO QID for 10 days
  • Fidaxomicin 200mg PO  BID for 10 days


Initial Episode, Fulminant (Hypotension or shock, ileus, megacolon)

  • Vancomycin 500 mg 4 times per day 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


First Recurrence

• Vancomycin 125 mg given 4 times daily for 10 days if metronidazole was used for the initial episode, OR

• Use a prolonged tapered and pulsed vancomycin regimen if a standard regimen was used for the initial episode (eg, 125 mg 4 times per day for 10–14 days, 2 times per day for a week, once per day for a week, and then every 2 or 3 days for 2–8 weeks), OR

•  Fidaxomicin 200 mg given twice daily for 10 days if Vancomycin was used for the initial episode



Photo Credit Photo by Gabor Monori on Unsplash



The Guidelines

  • McDonald, L. Clifford, 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 66.7 (2018): e1-e48. PMID:29462280

Original Studies

  • Teasley, DavidG, et al. “Prospective randomised trial of metronidazole versus vancomycin for Clostridium-difficile-associated diarrhoea and colitis.” The Lancet 322.8358 (1983): 1043-1046. PMID:6138597
  • Wenisch, C., et al. “Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of Clostridium difficile—associated diarrhea.” Clinical infectious diseases22.5 (1996): 813-818. PMID:8722937
  • New Evidence Favoring Vancomycin
  • Zar, Fred A., et al. “A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile–associated diarrhea, stratified by disease severity.” Clinical Infectious Diseases 45.3 (2007): 302-307. PMID:17599306
  • Johnson, Stuart, et al. “Vancomycin, metronidazole, or tolevamer for Clostridium difficile infection: results from two multinational, randomized, controlled trials.” Clinical Infectious Diseases 59.3 (2014): 345-354. PMID: 24799326

CDC C. Diff Statistics


New York Times article on the association of the rise of new sweeteners and the rise of C. diff.

The Germs That Love Diet Soda

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