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Big Changes in C. difficile Treatment Recommendations

C. difficile is at the top of the list of superbug threads in the U.S. 1 and infections continue to grow in number and increase in severity 2. One of the biggest challenges with C. difficile is that there are only a few antibiotic drugs that work against it, and one of those drugs (Flagyl) has lost much of its effectiveness in recent years.

Therefore in 2017, the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) released new guidelines 3 for which drugs should be prescribed for C. difficile. They also listed a relatively new and rather unorthodox treatment option for people with recurring infections.

Is Flagyl Finished?

The new guideline for treating first-time C. diff. infections is to avoid the once-popular drug Flagyl (metronidazole) in favor or either vancomycin or fidaxomicin when possible. This is a big change from the previous guidance, which favored Flagyl as a first-line treatment.

For people who have a single recurrence of C. difficile, the old treatment recommendation was to simply repeat the same antibiotics that were prescribed for the initial infection. The 2017 guidance no longer recommends a repeat of the same antibiotic. Instead, a longer and more aggressive course of tapered or pulsed vancomycin or fidaxomicin is the new recommendation.

New Prospects for Poo

Another major change in the IDSA guidelines is that for people with more than one recurrence of infection, fecal microbiota transplantation (FMT) is now one of the recommended treatments. This unconventional treatment has become popular over the last several years, despite the unpleasant idea of receiving other people’s fecal material. In fact, recent study results show that FMT can provide good results with few side effects.

Other recommendations for multiple recurrences of C. diff. include a combination of aggressive vancomycin treatment combined with the drug rifaximin, or use of fidaxomicin alone.

What This Means for You

The new treatment recommendations described above are important if you are under mainstream medical care and if you choose to use mainstream C. diff. treatments, such as antibiotics.

If you are being treated for C. difficile with antibiotics, especially if it’s your first infection, then it’s important to know that the popular drug Flagyl is no longer very effective. If your doctor prescribes Flagyl, you can ask them why other, more effective options were not prescribed instead.

If you are having a single recurrence of C. difficile, then the new guidance is to avoid taking the same drugs you took for your first infection. And if you’ve had multiple recurrences, then a fecal transplant is now one of the recommended treatment options.



  1. Centers for Disease Control and Prevention, Biggest Threats: https://www.cdc.gov/drugresistance/biggest_threats.html
  2. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015; 372(9):825-834, Lessa FC et al.
  3. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA)


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