Clinical Scorecard: Approaches to Address Clostridioides difficile Infections in Hematological Malignancy Patients: Insights from the European Conference on Infections in Leukemia and the Infectious Diseases Working Party of the European Society for Blood and Marrow Transplantation

At a Glance

Key Highlights

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

• Vancomycin was the most frequently reported first-line treatment for nonsevere CDI.

• Fidaxomicin was preferred for recurrent CDI, particularly when vancomycin had been used for the initial episode.

• Severe-complicated CDI was most often treated with intravenous metronidazole plus vancomycin.

• For second or later recurrence, 31% of centers reported using fecal microbiota transplantation; 65% did not consider it safe during agranulocytosis.

Guideline-Based Recommendations

Diagnosis

At diarrhea onset, 86% of centers routinely tested for C. difficile and other enteric pathogens. The survey also identified limitations in conventional CDI severity criteria for patients with hematological malignancies.

Management

Vancomycin was the most frequently reported first-line treatment for nonsevere CDI. For severe-complicated CDI, combination therapy with intravenous metronidazole and vancomycin was the most commonly reported approach. Fidaxomicin was preferred for recurrent CDI.

Monitoring & Follow-up

Severity assessment should account for the limitations of criteria commonly used in the general population. Severe diarrhea and severe abdominal pain were among the most commonly selected severity indicators, whereas leukocytosis and hypoalbuminemia were considered less useful.

Risks

Patients with hematological malignancies are particularly susceptible to CDI because of prolonged hospitalization, broad-spectrum antibiotic exposure, and altered gut microbiota. Neutropenia after hematopoietic cell transplantation or remission-induction chemotherapy was identified as the period of highest CDI risk.

Patient & Prescribing Data

The survey included 49 experts from different centers, including hematologists and infectious disease specialists. Most centers used the standard 10-day CDI treatment course.

Treatment choices were influenced by efficacy, institutional experience with vancomycin and metronidazole, recurrence risk with fidaxomicin, and, for some respondents, cost-effectiveness.

Clinical Best Practices

• Review and, when feasible, discontinue non-CDI antibiotics in patients diagnosed with CDI.

• Optimize the use and duration of available CDI therapies; the survey identified this as an unmet need, including further consideration of tapered or pulsed fidaxomicin regimens.

• Consider tapered or pulsed regimens for recurrent CDI.

• For second or later recurrence, 31% of centers reported using fecal microbiota transplantation. Among experts, 86% considered it useful in non-neutropenic patients, preferably after interdisciplinary discussion, while 65% did not consider it safe during agranulocytosis; the authors state that its use in this population requires further investigation.

Related Resources & Content

• Management of Clostridioides difficile infections in patients with hematological malignancies – a survey by European Conference on Infections in Leukemia (ECIL) and Infectious Diseases Working Party (IDWP) of The European Society for Blood and Marrow Transplantation (EBMT) — Agnieszka Piekarska, Chiara Oltolini, Benjamin W. Teh, Christine Robin, Dionysios Neofytos, Elena Reigadas, Andreas H. Groll, Patricia Muñoz, Lidia Gil, Roy F. Chemaly, Malgorzata Mikulska — International Journal of Infectious Diseases — 2026.

• 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.

• 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.

• 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.

• 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.