Approaches to Address Clostridioides difficile Infections in Hematological Malignancy Patients

Overview

This survey examines current practices for managing Clostridioides difficile infection (CDI) in patients with hematological malignancies, including incidence, diagnostic testing, severity assessment, treatment of initial and recurrent infection, and use of fecal microbiota transplantation. The findings identify variation in practice and several unmet needs that informed development of ECIL-10 recommendations for this population.

Background

Clostridioides difficile infection (CDI) is the leading cause of infectious diarrhea among hospitalized patients. Patients with hematological malignancies are particularly susceptible because of prolonged hospitalization, broad-spectrum antibiotic exposure, and alterations in gut microbiota. CDI management in this population is complicated by the limited applicability of conventional severity criteria, because commonly used measures such as leukocytosis, hypoalbuminemia, and fever may be affected by other clinical factors in patients with hematological malignancies.

Data Highlights

Key Findings

• Among centers reporting adult CDI rates in patients with hematological malignancies, 46% reported rates of 5% to 10%.

• At diarrhea onset, 86% of centers routinely tested for C. difficile and other enteric pathogens.

• Vancomycin was the most frequently reported first-line therapy for nonsevere CDI, accounting for 65% of responses.

• For severe-complicated CDI, intravenous metronidazole plus vancomycin was the most commonly reported combination therapy.

• Fidaxomicin was the preferred treatment for first recurrence in 46% of responses, particularly when vancomycin had been used for the initial episode.

• For second or later recurrence, fidaxomicin was preferred by 65% of respondents, and 31% of centers reported using fecal microbiota transplantation.

Clinical Implications

The survey highlights the need for CDI management approaches that account for the clinical characteristics of patients with hematological malignancies. Conventional severity criteria may be difficult to interpret in this population, highlighting the need for HM-specific severity criteria. The findings also identify unmet needs involving optimization of treatment selection and duration, access to intravenous treatment for patients unable to take oral therapy, and further evaluation of microbiome-based therapies.

Conclusion

The survey identified discrepancies in current CDI management practices among patients with hematological malignancies. The authors highlight the need for better-defined severity criteria, optimization of available therapies and treatment duration, access to intravenous treatment options, and additional safety studies of microbiome-based therapies.

Related Resources & Content

1. Management of Clostridioides difficile infection in patients with haematological malignancies and after cellular therapy: guidelines from 10th European Conference on Infections in Leukaemia (ECIL-10) — Mikulska M, Robin C, Neofytos D, Oltolini C, Piekarska A, Reigadas E, et al. — EClinicalMedicine — 2025.

2. Clostridioides difficile infection in non-transplanted adults with haematological malignancy: systematic review and meta-analysis on behalf of European Conference on Infections in Leukemia (ECIL) and Infectious Diseases Working Party (IDWP) of the European Society for Blood and Marrow Transplantation (EBMT) — Oltolini C, Piekarska A, Signori A, Robin C, Neofytos D, Reigadas E, et al. — Blood Reviews — 2026.

3. Comparative effectiveness of different therapies for Clostridioides difficile infection in adults: a systematic review and network meta-analysis of randomized controlled trials — Bednarik DS, Foldvari-Nagy KC, Simon V, Rancz A, Gede N, Veres DS, et al. — Lancet Regional Health Europe — 2025.

4. Effective treatment of Clostridioides difficile infection improves survival and affects graft-versus-host disease: a multicenter study by the Polish Adult Leukemia Group — Piekarska A, Sadowska-Klasa A, Mensah-Glanowska P, Sobczyk-Kruszelnicka M, Drozd-Sokolowska J, Waszczuk-Gajda A, et al. — Scientific Reports — 2024.

5. Extended-pulsed fidaxomicin versus vancomycin for Clostridium difficile infection: EXTEND study subgroup analyses — Cornely OA, Vehreschild M, Adomakoh N, Georgopali A, Karas A, Kazeem G, et al. — European Journal of Clinical Microbiology & Infectious Diseases — 2019.