What is the treatment for Clostridioides difficile diarrhea in an immunocompromised patient?

From the Guidelines

The treatment for Clostridioides difficile diarrhea in an immunocompromised patient typically involves oral vancomycin or fidaxomicin as first-line therapy, with fidaxomicin 200 mg twice daily for 10 days being the preferred option due to its efficacy in reducing recurrence rates 1. For initial episodes, oral vancomycin 125 mg four times daily for 10-14 days is also recommended. In severe cases, higher doses of vancomycin (up to 500 mg four times daily) may be used, and in fulminant cases, intravenous metronidazole 500 mg every 8 hours can be added as adjunctive therapy. Some key points to consider in the treatment of Clostridioides difficile diarrhea in immunocompromised patients include:

• Discontinuing the inciting antibiotic if possible
• Providing supportive care with fluid and electrolyte replacement
• Implementing strict infection control measures to prevent transmission
• Considering fecal microbiota transplantation for multiple recurrences, although its use in severely immunocompromised patients is not recommended due to limited evidence and potential risks 1
• Using adjunctive treatments such as bezlotoxumab 10 mg/kg given intravenously once during administration of standard of care antibiotics, with caution in patients with congestive heart failure 1. It's essential to note that immunocompromised patients are at higher risk for severe disease because their weakened immune systems struggle to control C. difficile proliferation and toxin production, making prompt and aggressive treatment crucial. The most recent and highest quality study, published in 2021, provides guidance on the management of Clostridioides difficile infection in adults, including recommendations for treatment and prevention of recurrence 1. Additionally, a 2024 study provides guidance on the use of fecal microbiota-based therapies for select gastrointestinal diseases, including Clostridioides difficile infection, and recommends their use in immunocompetent adults with recurrent C difficile infection upon completion of standard of care antibiotics 1.

From the FDA Drug Label

DIFICID® is indicated in adult and pediatric patients aged 6 months and older for the treatment of C. difficile-associated diarrhea (CDAD). To reduce the development of drug-resistant bacteria and maintain the effectiveness of DIFICID and other antibacterial drugs, DIFICID should be used only to treat infections that are proven or strongly suspected to be caused by C. difficile. The treatment for Clostridioides difficile diarrhea in an immunocompromised patient is fidaxomicin (PO), as it is indicated for the treatment of CDAD in adult and pediatric patients aged 6 months and older 2, 2.

• Key points:
  • Fidaxomicin is used to treat CDAD.
  • It is effective in adult and pediatric patients aged 6 months and older.
  • The treatment should be used to treat infections proven or strongly suspected to be caused by C. difficile.

From the Research

Treatment for Clostridioides difficile Diarrhea in Immunocompromised Patients

• The treatment for Clostridioides difficile diarrhea in immunocompromised patients typically involves oral vancomycin as the first-line therapy 3.
• Fidaxomicin is a good alternative, especially in patients at risk of relapse 3.
• Vancomycin combined with faecal microbiota transplantation remains the primary therapy for multiple recurrent CDI 3.
• In some cases, empirical antimicrobial therapy may be necessary, such as in patients with febrile diarrheal illness, with fever and bloody diarrhoea, symptoms persisting for >1 week, or immunocompromised status 4.

Additional Treatment Options

• Oral administration of human serum immunoglobulins has been reported to be effective in treating immunocompromised patients with viral gastroenteritis caused by viruses like rotavirus and norovirus 5.
• A study found that oral immunoglobulin (OIG) was effective in treating hospitalized immunocompromised children with diarrheal illness, with 95% of patients showing improvement 5.

Diagnostic Approach

• The incorporation of gastrointestinal (GI) multiplex polymerase chain reaction (PCR) panels has led to a paradigm shift in the approach to diarrhea in immunocompromised patients 6.
• A stepwise diagnostic algorithm is proposed to ensure diagnostic stewardship, optimal patient care, and resource utilization 6.