Global Practice Variation in the Management of Clostridioides difficile Infections: An International Cross-Sectional Survey of Clinicians

Connor Prosty; Émilie Bortolussi-Courval; Jimmy Lee; Todd C Lee; Emily G McDonald

doi:10.1093/ofid/ofaf248

Global Practice Variation in the Management of Clostridioides difficile Infections: An International Cross-Sectional Survey of Clinicians

Open Forum Infect Dis. 2025 Apr 24;12(5):ofaf248. doi: 10.1093/ofid/ofaf248. eCollection 2025 May.

Authors

Connor Prosty^{1

2}, Émilie Bortolussi-Courval², Jimmy Lee², Todd C Lee^{2

3

4}, Emily G McDonald^{2

4

5}

Affiliations

¹ Faculty of Medicine, McGill University, Montréal, Quebec, Canada.
² Division of Experimental Medicine, Department of Medicine, McGill University, Montréal, Quebec, Canada.
³ Division of Infectious Diseases, Department of Medicine, McGill University Health Centre, Montréal, Quebec, Canada.
⁴ Clinical Practice Assessment Unit, Department of Medicine, McGill University Health Centre, Montréal, Quebec, Canada.
⁵ Division of General Internal Medicine, Department of Medicine, McGill University Health Centre, Montréal, Quebec, Canada.

Abstract

Background: Clostridioides difficile infections (CDIs) are associated with significant morbidity, mortality, and economic burden globally. International guidelines conflict on various aspects of management, so we conducted a clinician survey to evaluate global practice variability on CDI diagnosis, treatment, and prophylaxis to inform future clinical trials.

Methods: An anonymous online survey through REDCap was distributed through multiple channels. Attending physicians, infectious disease pharmacists, and fellows in infectious diseases or medical microbiology who had managed ≥3 cases of CDI in the preceding year were eligible. Responses were compared across continents by chi-square test.

Results: Three hundred fifty-nine survey responses were collected from 31 countries and 6 continents (North America 80.5%, Europe 11.7%, other continents 7.8%). A 2-step CDI diagnostic algorithm was used by 75.8% of respondents with heterogeneity in assay type. Similarly, there was significant variability in first-line agents for the treatment of first episodes and first recurrences of uncomplicated CDI and a lack of consensus on treatments for fulminant CDI. Secondary CDI prophylaxis during antibiotic re-exposure was most commonly used in North America (84.1%), followed by other continents (50.0%) and Europe (31.0%; P < .001). Oral vancomycin was the most frequently used agent (96.3%), with significant variability in the dose (125-500 mg daily) and duration (1-28 days; P < .01).

Conclusions: Substantial global variability exists with respect to CDI diagnosis, treatment, and secondary prophylaxis, likely due to divergent guidelines and a paucity of robust evidence. These findings highlight critical knowledge gaps and areas of clinical equipoise and underscore the need for further randomized controlled trials to establish harmonized international best practices for CDI.

Keywords: Clostridioides difficile; international; prophylaxis; survey; vancomycin.