From the Guidelines
For recurrent C. difficile infection, the recommended treatment is fidaxomicin 200 mg orally twice daily for 10 days, or consider fecal microbiota transplantation (FMT), as suggested by the most recent guidelines 1. The management approach for recurrent Clostridioides difficile (C. diff) infection involves several strategies to reduce morbidity, mortality, and improve quality of life.
- First recurrence: Vancomycin 125 mg orally four times daily for 10 days, followed by a tapered and pulsed regimen, is a recommended treatment option 1.
- Second or subsequent recurrence: Fidaxomicin 200 mg orally twice daily for 10 days, or consider fecal microbiota transplantation (FMT), are recommended treatment options 1. Tapered and pulsed vancomycin regimen:
- 125 mg four times daily for 7 days
- 125 mg twice daily for 7 days
- 125 mg once daily for 7 days
- 125 mg every 2-3 days for 2-8 weeks Additionally, discontinuing any unnecessary antibiotics and implementing strict infection control measures are crucial to prevent further recurrences 1. Fidaxomicin has a narrower spectrum of activity and may better preserve the gut microbiome, while FMT works by directly restoring a diverse, healthy gut microbiome to outcompete C. difficile 1. It is essential to note that the treatment approach may vary depending on the individual patient's condition, and the decision to use FMT should be made on a case-by-case basis, considering the patient's risk factors and medical history 1.
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 management approach for recurrent Clostridioides difficile (C. diff) infection is not directly stated in the provided drug label. However, it can be inferred that vancomycin hydrochloride may be used to treat CDAD, and the label provides information on the recurrence rates of CDAD after treatment with vancomycin hydrochloride.
- The recurrence rates of CDAD were 23% and 18% in Trial 1 and Trial 2, respectively 2. It is essential to note that the label does not provide a specific management approach for recurrent C. diff infection.
From the Research
Management Approach for Recurrent Clostridioides difficile (C. diff) Infection
The management approach for recurrent Clostridioides difficile (C. diff) infection involves several treatment options, including:
- Extended duration vancomycin (EDV) regimens, which have been shown to be effective in treating recurrent C. diff infection 3
- Vancomycin course and taper, which is recommended for second recurrences 4
- Fecal bacteriotherapy, rifaximin "chaser" therapy, nitazoxanide, probiotics, and intravenous immunoglobulin, which are alternative agents that may be effective in treating recurrent C. diff infection 4, 5
- Fidaxomicin, which has been approved for the treatment of C. diff infection and may be a good alternative for patients at risk of relapse 6, 7
Treatment Regimens
The following treatment regimens have been studied:
- EDV regimens, which involve a daily dosing taper followed by an every 48 or 72 h pulse 3
- Vancomycin 125 mg q 6 h for 10-14 days, followed by a taper and pulse regimen 4
- Fidaxomicin 200 mg twice daily for 10 days, compared to vancomycin 125 mg four times daily for 10 days followed by a 3-week vancomycin taper and pulse regimen 6
Risk Factors and Outcomes
Several risk factors have been identified for recurrent C. diff infection, including: