From the Guidelines
For Clostridioides difficile (C. diff) colitis, oral vancomycin is the recommended treatment at a dose of 125 mg four times daily for 10 days, as supported by the most recent guidelines from the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 1.
Key Considerations
- The dose may be increased to 500 mg four times daily for severe or complicated infections.
- In cases of fulminant C. diff infection with hypotension, shock, or ileus, a higher dose of 500 mg four times daily should be used, potentially combined with intravenous metronidazole 500 mg every 8 hours.
- For recurrent C. diff infections, a tapered and pulsed regimen may be used: 125 mg four times daily for 10-14 days, then 125 mg twice daily for 7 days, then 125 mg once daily for 7 days, followed by 125 mg every 2-3 days for 2-8 weeks.
Rationale
- Vancomycin is preferred over metronidazole for initial episodes because it has higher cure rates and lower recurrence rates, as shown in a systematic review and meta-analysis comparing the efficacy and safety of metronidazole monotherapy with vancomycin monotherapy and combination therapy in CDI patients 1.
- Vancomycin works by inhibiting bacterial cell wall synthesis and is not absorbed systemically when given orally, allowing it to reach high concentrations in the intestinal lumen where the infection is located.
- Patients should complete the full course of treatment even if symptoms improve before completion to prevent recurrence.
Additional Options
- Fidaxomicin 200 mg twice daily for 10 days may be a valid alternative to vancomycin in patients with CDI, especially in patients at higher risk for recurrence, as suggested by the IDSA and SHEA guidelines 1.
- Bezlotoxumab may be considered as adjunctive treatment for patients with recurrent CDI or those at high risk for recurrence, although its use depends on available resources and logistics for intravenous administration.
From the FDA Drug Label
2.1 Adults Vancomycin Hydrochloride Capsules are used in treating C. difficile-associated diarrhea and staphylococcal enterocolitis. C. difficile-associated diarrhea: The recommended dose is 125 mg administered orally 4 times daily for 10 days.
The recommended vancomycin dosing for C. difficile-associated diarrhea (also known as C. diff colitis) in adults is 125 mg orally 4 times daily for 10 days 2.
- Key points:
- Dose: 125 mg
- Frequency: 4 times daily
- Duration: 10 days
- This dosing regimen is also supported by other sources, including 2 and 2.
From the Research
Vancomycin Dosing for C. Diff Colitis
- The standard dosing for vancomycin in the treatment of C. diff colitis is 125 mg four times daily orally for 10 days, as seen in the study 3.
- This dosing regimen has been compared to fidaxomicin in several studies, with fidaxomicin showing a lower rate of recurrence 3, 4.
- Vancomycin is recommended as first-line therapy for an initial episode of mild/moderate or severe CDI, with consideration of fidaxomicin for patients at particularly high risk for recurrence 5.
- For non-severe recurrent disease, the initial treatment regimen should be repeated, while subsequent episodes are more appropriately treated with a tapered and pulsed dose of vancomycin, fidaxomicin, or fecal microbiota transplantation 5.
Treatment Approaches
- Metronidazole is regarded as the agent of choice for CDI therapy and also for the first recurrence in most patients with mild to moderate CDI 6.
- Fidaxomicin is available for clinical use and is as effective as vancomycin with lower relapse rates 6.
- Rifaximin and fecal bacteriotherapy are alternative approaches in patients with severe or refractory CDI, before surgical intervention 6.
- Newer modalities of treatment have been developed including bezlotoxumab, a monoclonal antibody and fecal microbiota transplant 7.
Recurrence and Resistance
- The rate of recurrence of C. diff colitis is high, with significantly fewer patients in the fidaxomicin group than in the vancomycin group having a recurrence of the infection 3, 4.
- The lower rate of recurrence was seen in patients with non–North American Pulsed Field type 1 strains 3.
- Drug resistance is a major concern, especially in the elderly population, critical care patients, and immunocompromised individuals who are at high risk of developing CDIs 7.