Outcomes associated with recent guideline recommendations removing metronidazole for treatment of non-severe Clostridioides difficile infection: a retrospective, observational, nationwide cohort study.

The 2017 Society for Healthcare Epidemiology of America (SHEA) and Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for Clostridioides difficile infection (CDI) removed metronidazole as a preferred option for initial episodes of non-severe CDI. The objective of this study is to determine if the shift away from metronidazole improve clinical outcomes of initial episodes of non-severe CDI. The study was a retrospective, observational, nationwide cohort study using a Veterans Health Administration national clinical administrative database. Adult patients treated for non-severe CDI pre- and post- the February 2018 publication of the 2017 IDSA/SHEA C. difficile Clinical Practice Guidelines were included. The primary outcome was the composite of treatment failure or probable recurrence. A total of 3,608 patients were included, with 1,809 in pre-guideline cohort (mean [SD] age, 65.5 [14.2] years; 1,602[88.6%] male) and 1799 in post-guideline cohort (mean [SD] age, 64[14.6] years; 1584[88%] male). Overall composite of treatment failure or probable recurrence was similar between both cohorts (318 of 1,809 [17.6%] pre-guideline cohort vs 317 of 1,799 [17.6%] post-guideline cohort [P=0.97]). The shift away from metronidazole as a preferred option in initial non-severe CDI did not improve the composite of treatment failure or recurrence.