From the Guidelines
The recommended treatment for Clostridioides difficile infection is fidaxomicin 200 mg twice daily for 10 days for initial mild to moderate cases, as it has been shown to have a lower recurrence rate compared to vancomycin 1. For initial mild to moderate cases, the treatment options include:
- Fidaxomicin 200 mg twice daily for 10 days
- Vancomycin 125 mg four times daily for 10 days For severe infections, the same regimens are used, though some clinicians may increase vancomycin to 500 mg four times daily. For fulminant C. diff with hypotension or shock, intravenous metronidazole 500 mg every 8 hours should be added to oral vancomycin 500 mg four times daily, with consideration for vancomycin enemas if ileus is present. For first recurrence, using fidaxomicin or a vancomycin taper and pulse regimen is preferred. For multiple recurrences, options include vancomycin followed by rifaximin, fidaxomicin extended regimens, fecal microbiota transplantation, or bezlotoxumab (a monoclonal antibody) 1. It's essential to discontinue unnecessary antibiotics, provide adequate hydration, and avoid antimotility agents which can mask symptoms and potentially worsen outcomes by trapping toxins in the colon. During treatment, probiotics may be helpful, and metronidazole (500 mg three times daily for 10 days) is now considered a second-line agent due to increasing treatment failures. Fecal microbiota transplantation is recommended for patients with multiple recurrences of CDI who have failed appropriate antibiotic treatments 1. Bezlotoxumab may also be considered for patients with other risks for CDI recurrence, but implementation depends upon available resources and logistics for intravenous administration 1.
From the FDA Drug Label
Vancomycin Hydrochloride Capsules are indicated for the treatment of C. difficile-associated diarrhea. The recommended dose is 125 mg administered orally 4 times daily for 10 days. DIFICID is a macrolide antibacterial indicated in adult and pediatric patients 6 months of age and older for the treatment of C. difficile-associated diarrhea. Adults: One 200 mg tablet orally twice daily for 10 days.
The recommended treatments for C. difficile infection are:
- Vancomycin: 125 mg orally 4 times daily for 10 days 2
- Fidaxomicin: 200 mg orally twice daily for 10 days 3
From the Research
Treatment Options for C diff Infection
- The primary treatment for Clostridioides difficile (C diff) infection is oral vancomycin, with a recommended dose of 125 mg four times daily 4, 5.
- Fidaxomicin is also a recommended treatment option, particularly for patients with recurrent C diff infection 6, 7.
- Metronidazole is no longer advised for management of outpatient C diff infection, and should only be used in mild-to-moderate disease in younger patients with no or few risk factors for recurrence 6, 7.
Vancomycin Dosing Regimens
- Studies have shown that high-dose and low-dose vancomycin regimens have similar treatment outcomes for C diff infection 4, 8, 5.
- A dose of 125 mg vancomycin four times daily is considered effective and is preferred due to its lower cost 5.
- However, some studies suggest that higher doses of vancomycin may be associated with lower rates of recurrence 4.
Alternative Treatment Options
- Bezlotoxumab, a monoclonal antibody, is available to prevent recurrences in patients with C diff infection 6, 7.
- Fecal microbiota transplantation (FMT) is also an option for patients with frequently recurring C diff infection 6, 7.
- Live biotherapeutics, such as microbiome-based therapies, are also being developed for the prevention of recurrent C diff infection 7.