Intended for healthcare professionals

Clinical Review State of the Art Review

Clostridioides difficile: diagnosis and treatments

BMJ 2019; 366 doi: (Published 20 August 2019) Cite this as: BMJ 2019;366:l4609
  1. Benoit Guery, professor of medicine1 2 3 6,
  2. Tatiana Galperine, clinical chief1 2,
  3. Frédéric Barbut, professor of microbiology4 5 6
  1. 1Infectious Diseases Service, Department of Medicine, University Hospital and University of Lausanne, Lausanne, Switzerland
  2. 2French Group of Faecal Microbiota Transplantation
  3. 3European Study Group on Host and Microbiota Interactions
  4. 4National Reference Laboratory for Clostridium difficile, Paris, France
  5. 5INSERM, Faculté de Pharmacie de Paris, Université Paris Descartes, Paris, France
  6. 6European Study Group on Clostridium difficile
  1. Correspondence to Benoit Guery benoit.guery{at}


Clostridioides difficile (formerly Clostridium) is a major cause of healthcare associated diarrhea, and is increasingly present in the community. Historically, C difficile infection was considered easy to diagnose and treat. Over the past two decades, however, diagnostic techniques have changed in line with a greater understanding of the physiopathology of C difficile infection and the use of new therapeutic molecules. The evolution of diagnosis showed there was an important under- and misdiagnosis of C difficile infection, emphasizing the importance of algorithms recommended by European and North American infectious diseases societies to obtain a reliable diagnosis. Previously, metronidazole was considered the reference drug to treat C difficile infection, but more recently vancomycin and other newer drugs are shown to have higher cure rates. Recurrence of infection represents a key parameter in the evaluation of new drugs, and the challenge is to target the right population with the adapted therapeutic molecule. In multiple recurrences, fecal microbiota transplantation is recommended. New approaches, including antibodies, vaccines, and new molecules are already available or in the pipeline, but more data are needed to support the inclusion of these in practice guidelines. This review aims to provide a baseline for clinicians to understand and stratify their choice in the diagnosis and treatment of C difficile infection based on the most recent data available.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Acknowledgments The authors would like to thank Kathy Darling for editing the manuscript.

  • Contributorship FB drafted the section on epidemiology and diagnosis, TG drafted the section on fecal microbiota transplantation, BG drafted the section on treatment, all authors appraised and amended the manuscript overall.

  • Declaration of interests We have read and understood the BMJ policy on declaration of interests and declare the following interests: BG reports personal fees, and non-financial support from Astellas, personal fees and non-financial support from MSD

  • TG reports personal fees, and non-financial support from Astellas, personal fees and non-financial support from MSD

  • FB reports grants, personal fees, and non-financial support from Astellas, personal fees from Pfizer, grants, personal fees and non-financial support from MSD

  • Further details of The BMJ policy on financial interests is here:

  • Provenance and peer review: commissioned; externally peer reviewed.

  • Patient involvement No patients were directly involved in the writing of this article.

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