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 acceptable alternative 1. For mild to moderate first episodes,
- oral vancomycin 125 mg four times daily for 10 days
- or fidaxomicin 200 mg twice daily for 10 days is recommended 1. For severe infections,
- the same regimens are used,
- but hospitalization may be necessary 1. 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. For recurrent infections,
- extended vancomycin tapers
- or fidaxomicin may be used,
- and fecal microbiota transplantation is highly effective for multiple recurrences 1. Supportive care includes
- fluid replacement,
- avoiding antiperistaltic medications,
- and discontinuing the inciting antibiotic if possible 1. Probiotics may help prevent recurrence by restoring gut microbiota 1. C. diff causes disease by producing toxins that damage the intestinal lining after normal gut flora is disrupted, typically by antibiotic use, allowing this opportunistic pathogen to flourish 1.
In terms of specific treatment regimens,
- fidaxomicin 200 mg twice daily for 10 days is recommended for initial episodes 1,
- and vancomycin 125 mg four times daily for 10 days is an acceptable alternative 1. For recurrent infections,
- extended vancomycin tapers
- or fidaxomicin may be used 1,
- and fecal microbiota transplantation is highly effective for multiple recurrences 1. Bezlotoxumab, a monoclonal antibody, may also be considered for patients with recurrent CDI, particularly those with severe CDI or at high risk for recurrence 1.
Overall, the treatment of C. diff infection should be individualized based on the severity of the infection, the patient's underlying health status, and the presence of any underlying conditions that may affect treatment outcomes 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).
Treatment for C. difficile-associated diarrhea (CDAD): Fidaxomicin (DIFICID) is indicated for the treatment of CDAD in adult and pediatric patients aged 6 months and older.
- The recommended dosage for adults is one 200 mg DIFICID tablet orally twice daily for 10 days.
- For pediatric patients, the dosage is based on weight, with tablets or oral suspension administered twice daily for 10 days 2.
From the Research
Treatment Options for C. difficile Infection
- Vancomycin is recommended as the first-line therapy for most cases of CDI, especially for severe disease 3
- Fidaxomicin is a good alternative, especially in patients at risk of relapse, and has been shown to be superior to metronidazole and vancomycin in some studies 4, 5
- Metronidazole is no longer recommended as primary therapy for the first episode of CDI or recurrent disease due to lower rates of treatment success compared to vancomycin 4, 3
- Faecal microbiota transplantation is effective and safe for the treatment of recurrent CDI 6, 4
Comparison of Treatment Outcomes
- Fidaxomicin has been shown to be superior to vancomycin and metronidazole for sustained clinical response and prevention of recurrent CDI in initial episode, first recurrence, and non-severe cases 5
- Vancomycin and fidaxomicin have similar outcomes for sustained clinical response and prevention of recurrent CDI in patients with multiple recurrences 5
- In the treatment of severe CDI, fidaxomicin has a similar treatment outcome to vancomycin, and none of the antibiotic treatments are superior in the prevention of recurrent CDI 5
Considerations for Concomitant Antibiotic Use
- Concomitant antibiotic use during the initial CDI episode is a major risk factor for recurrent CDI 7
- A study comparing fidaxomicin with oral vancomycin for the treatment of CDI in hospitalized patients receiving concomitant antibiotics found similar rates of clinical cure and recurrent CDI between the two groups 7