From the Guidelines
The cause of recurrent Clostridioides (C.) difficile infection is multifactorial, including the administration of other antibiotics during or after initial treatment of CDI, a defective humoral immune response against C. difficile toxins, advancing age, and increasingly severe underlying disease, as well as continued use of proton pump inhibitors (PPIs) 1. The risk factors for CDI recurrence are numerous and include the use of antibiotics, which can disrupt the normal gut microbiota, allowing C. difficile to overgrow and cause infection. A defective humoral immune response against C. difficile toxins can also contribute to recurrence, as well as advancing age and increasingly severe underlying disease 1. Some key points to consider in the management of recurrent CDI include:
- Discontinuing any unnecessary antibiotics and PPIs if possible
- Ensuring proper hand hygiene and environmental cleaning to prevent spread
- Considering treatment with vancomycin or fidaxomicin for initial and subsequent recurrences
- Using a tapered and pulsed vancomycin regimen to eliminate residual spores
- Restoring normal gut flora through fecal microbiota transplantation (FMT) for patients with multiple recurrences who have failed to resolve their infection despite treatment attempts with antibiotic agents targeting CDI 1. It is essential to note that the treatment approach should prioritize the restoration of a healthy bacterial balance in the intestines, which is crucial in preventing recurrence. Fidaxomicin has been shown to be more effective than vancomycin in reducing the risk of recurrence, particularly in patients with a first recurrence of CDI 1. In patients with multiple recurrences, FMT has been shown to be a viable alternative treatment approach, with high success rates and a low risk of adverse events 1. Overall, the management of recurrent CDI requires a comprehensive approach that takes into account the various risk factors and treatment options available, with the goal of restoring a healthy gut microbiome and preventing further recurrences.
From the FDA Drug Label
In subjects with diarrhea resolution at end-of-treatment with Vancomycin Hydrochloride Capsules, recurrence of CDAD during the following four weeks occurred in 25 of 107 (23%) and 18 of 102 (18%) in Trial 1 and Trial 2, respectively. The cause of recurrent Clostridioides (C.) difficile infection is not directly stated in the drug label.
- The label reports the recurrence rates of CDAD in subjects treated with vancomycin hydrochloride capsules, but does not provide information on the underlying cause of these recurrences 2.
From the Research
Causes of Recurrent Clostridioides (C.) difficile Infection
The causes of recurrent Clostridioides (C.) difficile infection can be attributed to several factors, including:
- Inadequate immune response to C. difficile toxins 3
- Persistent disruption of the normal colonic flora 3
- Advanced age 3
- Continuation of other antibiotics 3
- Prolonged hospital stays 3
- The emergence of more virulent strains, such as C. difficile strain BI/NAP1/027 4
Risk Factors for Recurrence
Several risk factors have been identified for recurrent C. difficile infection, including:
- Previous episode of C. difficile infection 5
- Severity of the initial infection 6, 3
- Use of antibiotics other than those used to treat C. difficile infection 3
- Advanced age 3
Mechanisms of Recurrence
The mechanisms of recurrence are not fully understood, but it is thought that the disruption of the normal colonic flora and the inadequate immune response to C. difficile toxins play a significant role 3. The use of antibiotics can also disrupt the normal colonic flora, leading to an increased risk of recurrence 3.
Treatment-Related Factors
Treatment-related factors, such as the use of metronidazole or vancomycin, can also influence the risk of recurrence 6, 5. Fidaxomicin has been shown to be superior to vancomycin in preventing recurrence in patients with a first recurrence of C. difficile infection 5.