From the Guidelines
The recommended treatment for Clostridioides difficile infection (CDI) is based on the severity and recurrence of the infection, with fidaxomicin and vancomycin being the preferred treatments for initial and recurrent episodes, respectively, as stated in the 2021 focused update guidelines by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 1.
Treatment Options
- For initial CDI episodes, fidaxomicin 200 mg twice daily for 10 days is the preferred treatment, with vancomycin 125 mg four times daily for 10 days being an acceptable alternative 1.
- For recurrent CDI, vancomycin in a tapered and pulsed regimen or fidaxomicin is recommended, with fecal microbiota transplantation being considered for multiple recurrences 1.
- In fulminant cases with hypotension or shock, oral vancomycin 500 mg four times daily plus intravenous metronidazole 500 mg every 8 hours is recommended, with consideration for surgical consultation 1.
Supportive Care
- Fluid and electrolyte replacement, avoiding antimotility agents, and discontinuing the inciting antibiotic if possible are important supportive care measures 1.
- Treatment should begin promptly upon diagnosis as CDI can rapidly progress to life-threatening complications including toxic megacolon and sepsis 1.
Fecal Microbiota Transplantation
- Fecal microbiota transplantation is recommended for patients with multiple recurrences of CDI who have failed appropriate antibiotic treatments, with a strong recommendation and moderate quality of evidence 1.
- The procedure involves instillation of processed stool collected from a healthy donor into the intestinal tract of the patient, with careful evaluation and selection of the donor to minimize the risk of iatrogenic infection 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). The recommended treatment for Clostridioides difficile infection (CDI) is fidaxomicin (PO), as indicated in the drug label for adult and pediatric patients aged 6 months and older 2.
- The treatment should be used to treat infections that are proven or strongly suspected to be caused by C. difficile.
- DIFICID should be used only when necessary to reduce the development of drug-resistant bacteria.
From the Research
Treatment Options for Clostridioides difficile Infection (CDI)
- The recommended treatment for CDI depends on the severity of the infection and whether it is an initial or recurrent episode 3, 4, 5.
- For an initial episode of non-severe CDI, oral vancomycin or oral fidaxomicin is recommended 4, 5.
- Metronidazole is no longer recommended as first-line therapy for adults due to lower rates of treatment success compared to vancomycin 4, 5.
- Fidaxomicin is a good alternative, especially in patients at risk of relapse, and has been shown to be associated with a lower risk of treatment failure compared to vancomycin 6.
Recurrent CDI Treatment
- Vancomycin combined with fecal microbiota transplantation remains the primary therapy for multiple recurrent CDI 3.
- Fecal microbiota transplantation is a reasonable treatment option with high cure rates in patients who have had multiple recurrent episodes and have received appropriate antibiotic therapy for at least three of the episodes 4, 5.
- Bezlotoxumab, a human monoclonal antibody, can be used in patients with high risk of recurrent CDI 7.
Emerging Therapies
- Several emerging potential therapies are in development, including ibezapolstat, MGB-BP-3, and DS-2969b, which target bacterial DNA replication, and CRS3213, which inhibits toxin production and spore formation 7.
- Other emerging therapies include ramizol and ramoplanin, which affect bacterial cell wall, and alanyl-L-glutamine, which inhibits damage caused by C. difficile by protecting intestinal mucosa 7.
Prevention and Management
- Good antibiotic stewardship is a key strategy to decrease rates of CDI 5.
- Hands should be cleaned with either soap and water or an alcohol-based product, but during outbreaks soap and water is superior 5.
- The Infectious Diseases Society of America does not recommend the use of probiotics for prevention of CDI 5.