Antibiotic therapy for Clostridium difficile infection

Antibiotic treatment of Clostridium difficile infection (CDI) in adults in the United States has been guided by the 2010 joint guidelines from the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA), but three new sets of guidelines became available in 2013, including one from the American College of Gastroenterology and two from Europe. This article will put these guidelines in perspective, review their recommendations, and cite the data from key primary references. Although varied definitions of disease severity are used, metronidazole is generally recommended for a first or second episode of non-severe CDI, low-dose oral vancomycin is preferred for severe CDI, and the combination of high-dose oral vancomycin plus intravenous metronidazole is reserved for complicated CDI. The roles of fidaxomicin and other measures are also discussed. However, the many caveats within the recommendations underscore the importance of clinical judgment in treating this evolving disease.