From the Guidelines
The management of Clostridioides difficile (C. diff) infection involves treating the initial episode with fidaxomicin or vancomycin, and using fecal microbiota transplantation for recurrent or refractory cases.
Treatment of Initial Episode
- For the initial episode of CDI, the preferred treatment is fidaxomicin 200 mg given twice daily for 10 days 1.
- An alternative treatment is vancomycin 125 mg given 4 times daily by mouth for 10 days 1.
- For nonsevere CDI, metronidazole 500 mg 3 times daily by mouth for 10–14 days can be used if fidaxomicin and vancomycin are unavailable 1.
Treatment of Recurrent Episode
- For the first recurrence of CDI, the preferred treatment is fidaxomicin 200 mg given twice daily for 10 days or vancomycin by mouth in a tapered and pulsed regimen 1.
- For second or subsequent recurrences, treatment options include fidaxomicin, vancomycin in a tapered and pulsed regimen, or vancomycin followed by rifaximin 1.
Fecal Microbiota Transplantation
- Fecal microbiota transplantation is recommended for patients with multiple recurrences of CDI who have failed appropriate antibiotic treatments 1.
- The AGA suggests select use of fecal microbiota–based therapies on completion of standard of care antibiotics to prevent recurrence in immunocompetent adults with recurrent C difficile infection 1.
- The BSG and HIS guidelines recommend offering FMT to all patients with two or more recurrences of CDI, and considering FMT for a first recurrence of CDI or as an adjunct to antibiotics in refractory CDI 1.
Fulminant CDI
- For fulminant CDI, treatment involves vancomycin 500 mg 4 times daily by mouth or by nasogastric tube, and possibly intravenously administered metronidazole 1.
From the Research
Management of Clostridioides difficile (C. diff) Infection
The management of Clostridioides difficile (C. diff) infection involves several strategies, including:
- Diagnosis and treatment of the infection
- Prevention of recurrence
- Management of severe and fulminant cases
Treatment Options
Treatment options for C. diff infection include:
- Vancomycin, which remains an acceptable therapy for an initial episode of CDI 2, 3, 4
- Fidaxomicin, which is now recommended for first-line therapy for most cases of CDI due to its effectiveness in preventing recurrence 2, 3, 4, 5
- Metronidazole, which is no longer recommended as primary therapy for the first episode of CDI or recurrent disease due to lower rates of treatment success compared to vancomycin 2
- Fecal microbiota transplantation (FMT), which is effective and safe for the treatment of recurrent CDI and can be considered for patients with severe and fulminant cases 2, 6, 4, 5
Prevention of Recurrence
Prevention of recurrence is an important aspect of C. diff management, and strategies include:
- Use of fidaxomicin and bezlotoxumab, which have been shown to be effective in preventing recurrence 2, 3, 4
- Fecal microbiota transplantation (FMT), which can be used to prevent recurrent CDI 2, 6, 4, 5
- Secondary prophylaxis with vancomycin in refractory CDI cases with risk factors who receive broad-spectrum antibiotics 4
Management of Severe and Fulminant Cases
Management of severe and fulminant cases of C. diff infection includes:
- High-dose oral and rectal vancomycin and IV metronidazole, as recommended by IDSA/SHEA guidelines 3
- Fidaxomicin and tigecycline as part of combination anti-CDI therapy, as endorsed by ESCMID guidelines 3
- Fecal microbiota transplantation (FMT), which can be considered for patients with severe and fulminant cases who are not responding to traditional anti-CDI antibiotics 6, 4, 5