Thread by @john_damianosMD

⭐️The new C. difficile guidelines!

Here are the 🧠s behind the new guidelines!

What's in a name?

Clostridium difficile ▶️ clostridioides difficile

Community acquired CDI is on the rise.

Diagnosis can be tricky!

GDH is sensitive but not specific
Toxin EIA is specific but not sensitive
PCR is sensitive, but not specific

Watch out for symptomatic colonization (+PCR)

PI-IBS occurs in about 25% of cases treated for CDI

Sensitive ▶️ specific

Metronidazole: cheapest
Oral vancomycin: 10x more $$$ than metronidazole
Fidaxomycin: 30x more $$$ than metronidazole; most narrow spectrum; prevents recurrence the best

Non-severe initial episode: vancomycin or fidaxomicin

IDSA: never use metronidazole
@AmCollegeGastro: can use metronidazole in low-risk patients

Severe initial episode: vancomycin or fidaxomicin

⛔️metronidazole

Fulminant: fluids, surgery consult, imaging, high dose vancomycin AND metronidazole

With ileus, consider vancomycin enema

If no response in 24-28 h, consider ✂️

New recommendation: can consider multiple (avg 3) #FMT +vanc for 1st episode

Pregnant: vanc, no metronidazole
Immunocompromised: vanc or fidaxo

#IBD: vanc for MINIMUM 14d; consider #FMT for rCDI

First recurrence: fidaxomicin or tapering/pulse dosed vancomycin

NNT = 3 for #FMT preventing CDI recurrence

Can use FMT at second recurrence (3rd episode). Colonoscopic or "crapsule." Repeat FMT if recur within 8 weeks of FMT

There is no role for #probiotics in the primary or secondary prevention of CDI; the guidelines explicitly recommend against.

#microbiome

Suppressive oral vancomycin in patients who are not candidates for #FMT or fail FMT

OVP can be considered in high risk patients getting antibiotics

Bezlotoxumab: consider in those with high risk of recurrence.

Careful in patients with heart failure

Do not discontinue PPI (unless they don't need in the first place!)