Severe, complicated or fulminant Clostridioides difficile infection

Seek expert advice for management of adults and children with severe, complicated or fulminant Clostridioides difficile infection (for definitions, see Severity assessment of C. difficile infection).

Management of severe, complicated or fulminant disease requires a collaborative, multidisciplinary approach that involves:

• an infectious diseases physician or a clinical microbiologist
• a gastroenterologist
• a general or gastrointestinal surgeon.

Early consideration for surgical intervention is indicated for patients with complicated or fulminant disease because outcomes are poor after organ dysfunction is established. Patients with complicated disease may require a colectomy to survive, particularly if toxic megacolon develops.

Recommendations for severe, complicated or fulminant disease are included in this topic for:

• adults
• children younger than 18 years.

For patients whose clinical condition fails to improve on the regimens below, seek expert advice. Surgical intervention should be considered. Limited data suggest that tigecycline may be a useful salvage therapy, and may be considered in consultation with an infectious diseases physicianBishop, 2018 McDonald, 2018van Prehn, 2021.

Emerging evidence suggests that faecal microbiota transplantation (FMT) may be effective for severe, complicated or fulminant C. difficile infection, but the optimal dose, route of administration and use of adjunctive antibiotics remain uncertainCostello, 2015Fischer, 2017Song, 2022Tixier, 2019. There may also be practical issues in obtaining faecal microbiota transplantation in the acute setting.

Data are lacking for use of fidaxomicin in severe complicated infection, life-threatening infection, fulminant disease and toxic megacolonCornely, 2012Cornely, 2013Guery, 2018Louie, 2011Mikamo, 2018.

For information about follow-up testing and patient education, see Follow-up for patients with Clostridioides difficile infection.