From the Guidelines
The most appropriate treatment for this patient is option A: Vancomycin 125 mg orally 4 times daily for 10 days followed by fecal microbiota transplantation. This patient has been treated with both vancomycin and fidaxomicin for C. difficile infection, but still has positive PCR tests and mild symptoms. The patient's clinical improvement with only mild residual symptoms suggests the infection has been adequately treated, but he may have developed post-infectious irritable bowel syndrome (PI-IBS) symptoms or may still have a disrupted gut microbiota. Given the patient's history of recurrent C. difficile infection, fecal microbiota transplantation (FMT) is a recommended treatment option 1, as it can help restore the normal balance of gut flora and reduce the risk of further recurrences. Vancomycin 125 mg orally 4 times daily for 10 days is a standard treatment for C. difficile infection, and followed by FMT may be a more effective approach 1 for patients with recurrent infection. Further antibiotic treatment alone is not indicated as it could disrupt gut flora further and potentially worsen symptoms. The patient should be reassured that positive PCR tests in this context do not indicate active infection requiring additional antibiotics. Additional treatments like dietary modifications, probiotics, or other antispasmodics might also be beneficial in managing the patient's symptoms.
From the Research
Treatment Options for Recurrent Clostridium difficile Infection
The patient has experienced recurrent Clostridium difficile infection despite treatment with azithromycin, vancomycin, and fidaxomicin. Considering the patient's history and the failure of previous treatments, the following options can be considered:
- Vancomycin 125 mg orally 4 times daily for 10 days followed by fecal microbiota transplantation (FMT) 2, 3
- Fidaxomicin 200 mg orally 2 times daily, although this treatment has already been tried and failed 3
- Vancomycin 125 mg oral 6-week taper with pulse, which may be considered for patients with recurrent infection 4
- FMT has been shown to be effective in treating recurrent C. difficile infection, with a study demonstrating 90% resolution of diarrhea in patients treated with FMT via colonoscopy 2
- Another study found that FMT was superior to fidaxomicin and vancomycin in treating recurrent C. difficile infection, with 71% of patients achieving combined clinical and microbiological resolution 3
Considerations for Fecal Microbiota Transplantation
FMT has been shown to be a highly effective treatment for recurrent C. difficile infection, with studies demonstrating significant improvements in clinical and microbiological outcomes 2, 3, 5. The use of FMT via colonoscopy has been found to be safe and effective, with minimal adverse events reported 2, 3, 5. The patient's symptoms and history suggest that FMT may be a suitable treatment option.
Vancomycin Treatment Regimens
Vancomycin has been used to treat C. difficile infection, with studies demonstrating its effectiveness in resolving diarrhea and improving clinical outcomes 4, 6. The use of vancomycin 125 mg orally 4 times daily for 10 days has been shown to be effective in treating C. difficile infection, although the patient has already been treated with this regimen 4. A 6-week taper with pulse regimen may be considered for patients with recurrent infection, although the evidence for this approach is limited 4.