Clostridioides difficile Colitis (CDI) — Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Severity grade
   Severity? (WBC/creatinine / fulminant signs) (Antibiotic-associated, toxin-producing C. difficile infection (CDI); triggers: antibiotics, advanced age, PPIs, hospitalization. Diarrhea (≥3 loose stools/24 h) + cramping pain/low-grade fever/raised WBC; spectrum: asymptomatic carriage → pseudomembranous colitis → fulminant (toxic megacolon/ileus/perforation/shock). Diagnosis: stool NAAT + toxin EIA in patients with significant diarrhea (do not test asymptomatic/formed stool). Severity: non-severe (WBC <15×10⁹ and creatinine <1.5 mg/dL) / severe (WBC ≥15 or creatinine ≥1.5) / fulminant (hypotension/shock/ileus/megacolon).)
   • Fulminant (shock/ileus/megacolon) → Fulminant → intensify + surgery
   • Non-severe–severe → Non-severe–severe · oral therapy
2. [End] Non-severe–severe · oral therapy
   Non-severe–severe: stop the inciting antibiotic where possible, hydrate and correct electrolytes, avoid antimotility agents; oral fidaxomicin (preferred) or oral vancomycin × 10 days (metronidazole only if the first two are unavailable and disease is non-severe); for recurrence use fidaxomicin / tapered-pulsed vancomycin, bezlotoxumab; for multiple recurrences → fecal microbiota transplant.
3. [End] Fulminant → intensify + surgery
   Fulminant (hypotension/shock, ileus, toxic megacolon): oral/NG vancomycin 500 mg q6h + IV metronidazole, add vancomycin retention enemas if ileus; aggressive resuscitation, CT assessment; surgical consult — perforation/megacolon/organ failure/no improvement → subtotal colectomy + end ileostomy (or diverting loop ileostomy + colonic lavage).

Source guidelines & references

• Clostridioides difficile infection (ACG 2021; IDSA/SHEA guidelines)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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