From the Guidelines
The treatment for Clostridioides difficile (C. diff) infection should be guided by the most recent clinical practice guidelines, which recommend fidaxomicin 200 mg twice daily for 10 days as the preferred treatment for initial episodes, and vancomycin 125 mg four times daily for 10 days as an alternative, with adjustments for severity and recurrence 1.
Treatment Approach
The approach to treating C. diff infection depends on the severity of the disease and whether it is an initial episode or a recurrence.
- For initial episodes, fidaxomicin 200 mg twice daily for 10 days is recommended as the preferred treatment, with vancomycin 125 mg four times daily for 10 days as an alternative 1.
- For recurrent infections, extended vancomycin tapers or fidaxomicin may be used, with fecal microbiota transplantation considered for multiple recurrences 1.
Severity-Based Treatment
The treatment also varies based on the severity of the infection:
- For fulminant C. diff with hypotension or shock, vancomycin 500 mg four times daily (orally or via nasogastric tube) plus intravenous metronidazole 500 mg every 8 hours is recommended, with surgical consultation for possible colectomy if condition deteriorates 1.
Supportive Care and Prevention
Supportive care includes:
- Fluid replacement
- Avoiding antimotility agents
- Discontinuing the inciting antibiotic if possible Infection control measures like contact precautions and hand hygiene with soap and water are essential to prevent transmission 1.
Evidence Quality and Recommendations
The recommendations are based on the most recent guidelines, which prioritize the use of high-quality evidence to guide treatment decisions 1.
- The use of fidaxomicin and vancomycin is supported by strong recommendations and moderate to high-quality evidence 1.
- Fecal microbiota transplantation is recommended for multiple recurrences, with strong recommendations and moderate-quality evidence 1.
From the FDA Drug Label
1 INDICATIONS AND USAGE 1.1 Clostridioides difficile-Associated Diarrhea DIFICID® is indicated in adult and pediatric patients aged 6 months and older for the treatment of C. difficile-associated diarrhea (CDAD).
2 DOSAGE AND ADMINISTRATION 2.1 Important Administration Instructions DIFICID is available for oral administration as 200 mg tablets and as granules for oral suspension (40 mg/mL (200 mg/5 mL) when reconstituted).
2.2 Adult Patients The recommended dosage for adults is one 200 mg DIFICID tablet orally twice daily for 10 days.
C. diff treatment with fidaxomicin (PO) is indicated for adult and pediatric patients aged 6 months and older. The recommended dosage for adults is 200 mg twice daily for 10 days 2.
From the Research
C Diff Treatment Options
- The preferred medication for a first episode of C Diff is oral vancomycin or fidaxomicin 3
- For patients who recur after the first episode, vancomycin taper pulse or fidaxomicin can be used 3
- Intravenous bezlotoxumab, a monoclonal antibody, is available to prevent recurrences 3, 4
- Fecal microbiota transplantation remains available in limited settings for recurrent C Diff 3, 4
Treatment Guidelines
- Metronidazole is no longer advised for management of outpatient C Diff 3
- Metronidazole should be used only in mild-to-moderate disease in younger patients who have no or only few risk factors for recurrence 4
- Vancomycin and fidaxomicin are the cornerstones for the treatment of C Diff 4
Comparative Efficacy of Treatments
- Low dose vancomycin is no different than high dose vancomycin for treatment of an initial episode of C Diff in terms of recurrence rate 5
- Fidaxomicin was superior to metronidazole, vancomycin or their combination, for a sustained clinical response and in the prevention of recurrent C Diff 6
- Fidaxomicin had a similar treatment outcome to vancomycin in the oral treatment of severe C Diff 6
- Fidaxomicin was superior to metronidazole or vancomycin for the treatment of the initial episode, first recurrence, and non-severe C Diff 6
Recent Studies
- A randomized, controlled, open-label trial found that rates of clinical cure and recurrent C Diff were similar for fidaxomicin and vancomycin in patients receiving concomitant antibiotics for concurrent infections 7
- The study found that only 4 patients developed recurrent C Diff, and overall recurrence was lower than anticipated in both arms compared with previous studies 7