AGA Guidance Addresses CDI Management in Patients With IBD
Clostridioides difficile infection (CDI) remains a major driver of disease flares, hospitalization, treatment failure, and surgery in patients with inflammatory bowel disease (IBD), according to an American Gastroenterological Association (AGA) expert review outlining best practice advice for diagnosis and management.
The review focuses on patients with underlying IBD who develop CDI or recurrent CDI, emphasizing that this population faces greater CDI risk, severity, and recurrence than individuals without IBD. The authors note that “CDI remains a significant driver of disease flares and poor outcomes in patients with inflammatory bowel disease,” creating challenges around antibiotic selection and whether to adjust IBD-directed therapy.
The AGA advises clinicians to exclude CDI in patients with IBD who develop new or worsening diarrhea, particularly those with colonic involvement. CDI should also be considered in patients with end ileostomy or ileo-anal pouch anastomosis who present with worsening diarrhea.
For an initial CDI episode in IBD, clinicians should preferentially use fidaxomicin, or vancomycin if fidaxomicin is unavailable or cost-prohibitive. “Metronidazole should not be used,” according to the best practice advice.
The review also emphasizes that IBD therapy should not be reflexively stopped during acute CDI. Concurrent IBD treatment is described as critical, with clinicians advised to continue required immunosuppressive therapies, including immunomodulators, biologics, or small molecules. Steroids may also be used if necessary while CDI is treated with antibiotics.
Hospitalization should be strongly considered for patients with severe colitis or systemic toxicity, including more than 6 bowel movements per day, severe abdominal pain, marked leukocytosis, hemodynamic instability, or sepsis.
For recurrent CDI, the AGA advises offering microbiome-based therapies, including FDA-approved donor-derived products or fecal microbiota transplantation, after at least 1 recurrence. Probiotics are not recommended for primary or secondary prevention.
Reference
Khanna S, Allegretti JR, Hashash JG, Feuerstadt P. AGA clinical practice update on management of clostridioides difficile infection in inflammatory bowel disease: Expert review. Gastroenterology. Published online May 15, 2026. doi:10.1053/j.gastro.2026.03.008
