Clinical update for the diagnosis and treatment of Clostridium difficile infection

Table 2 Comparison of American College of Gastroenterology 2013 and Society for Healthcare Epidemiology of America/Infectious Diseases Society of America 2010 Guidelines for Treatment of Clostridium difficile infection (Differences between the guidelines are in bold)

	SHEA/IDSA 20101		ACG 20132
Severity	Definition	Treatment	Definition	Treatment
Mild-to- Moderate	WBC < 15000 cells/μL or lower and serum Cr < 1.5 times the premorbid level	Metronidazole 500 mg 3 times/d by mouth for 10-14 d	Diarrhea plus any additional signs or symptoms not meeting severe or complicated criteria	Metronidazole 500 mg orally 3 times/d for 10 d. If no improvement in 5-7 d, consider change to vancomycin at standard dose.
Severe	WBC > 15000 cells/μL or higher or a serum Cr > or equal to 1.5 times the premorbid level	Vancomycin 125 mg 4 times/d by mouth for 10-14 d	Serum albumin < 3 g/dL plus one of the following: WBC ≥ 15000 or abdominal tenderness	Vancomycin 125 mg orally 4 times/d by mouth for 10 d
Severe, complicated	Hypotension or shock, ileus, megacolon	Vancomycin 500 mg four times/d by mouth or by nasogastric tube, plus metronidazole 500 mg every 8 h intravenously. If complete ileus, consider adding rectal installation of vancomycin	Any of the following attributable to CDI: ICU admission, hypotension with or without the need for vasopressors, fever ≥ 38.5 °C, ileus or significant abdominal distension, mental status changes, WBC > 35000 cells/mm3 or < 2000 cells/mm3, serum lactate > 2.2 mmol/L, end organ failure	Vancomycin 500 mg orally four times/d and metronidazole 500 mg IV every 8 h and vancomycin per rectum (500 mg in 500 mL saline as enema) four times a day

¹Society for Healthcare Epidemiology of America (SHEA)/Infectious Diseases Society of America (IDSA)[31];

²American College of Gastroenterology (ACG)[71].WBC: white blood cell; CDI: Clostridium difficile infection; ICU: Intensive care unit.