Clostridioides difficile Infection Clinical Practice Guidelines (ASCRS, 2021)

American Society of Colon and Rectal Surgeons

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

August 10, 2021

Guidelines for the management of Clostridioides difficile infection were published in June 2021 by the American Society of Colon and Rectal Surgeons (ASCRS) in Diseases of the Colon and Rectum[1]


When Clostridioides difficile infection (CDI) is suspected, perform a disease-specific history emphasizing risk factors, symptoms, comorbidities, and signs of severe or fulminant disease.

Evaluate patients to determine severity of CDI and presence of peritonitis or multisystem organ failure.

Diagnosis of CDI should include two-step laboratory stool testing to increase accuracy.

Routine endoscopic evaluation to diagnose or determine the extent of CDI is not recommended.


Oral vancomycin or fidaxomicin is first-line treatment for an initial CDI.

Metronidazole alone is no longer considered appropriate first-line treatment for CDI.


Reserve surgery for C difficile colitis for patients with colonic perforation or severe colitis who do not improve with medical therapy.

Subtotal colectomy with end ileostomy is recommended for severe-complicated or fulminant C difficile colitis.

A diverting loop ileostomy with antegrade colonic lavage may be an alternative to subtotal colectomy for the treatment of severe-complicated or fulminant CDI.

Recurrent and Refractory CDI

A prolonged course of vancomycin, adding bezlotoxumab or using fidaxomicin, is an acceptable therapy for recurrent or refractory CDI in stable patients.

Patients with recurrent or refractory CDI should be considered for fecal bacteriotherapy if conventional measures have failed.

For more information, go to Clostridioides (Clostridium) Difficile Colitis.


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