From the Guidelines
The essential treatment for Clostridioides difficile (C. diff) infection is oral vancomycin or fidaxomicin, which have become the first-line therapies, as recommended by the 2021 focused update guidelines by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 1. For an initial mild to moderate episode, oral vancomycin 125 mg four times daily for 10 days or fidaxomicin 200 mg twice daily for 10 days is recommended. Some key points to consider in the treatment of C. diff infection include:
- Discontinuing the inciting antibiotic if possible
- Providing supportive care with fluid and electrolyte replacement
- Avoiding antimotility agents which can mask symptoms and potentially worsen outcomes by retaining toxins in the colon
- Considering fecal microbiota transplantation after multiple recurrences
- Using vancomycin and fidaxomicin as equally effective options for resolving CDI symptoms, but with fidaxomicin associated with a lower likelihood of CDI recurrence after a first recurrence 1
- Using metronidazole as a second-line option, primarily when access to first-line agents is limited, and avoiding its use for long-term therapy due to the potential for cumulative neurotoxicity 1. It's also important to note that for fulminant C. diff with hypotension or shock, intravenous metronidazole may be added to oral vancomycin therapy, and surgical consultation should be obtained for possible colectomy in life-threatening cases 1. Overall, the treatment of C. diff infection should prioritize the use of vancomycin and fidaxomicin as first-line therapies, with consideration of patient-specific factors and the potential need for alternative treatments in certain cases.
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 essential treatment for C. diff patients is fidaxomicin (PO), which is indicated for the treatment of C. difficile-associated diarrhea (CDAD) in adult and pediatric patients aged 6 months and older 2. The recommended dosage for adults is one 200 mg DIFICID tablet orally twice daily for 10 days 2.
- Key points:
- Fidaxomicin (PO) is the essential treatment for C. diff patients.
- The treatment is indicated for adult and pediatric patients aged 6 months and older.
- The recommended dosage for adults is one 200 mg DIFICID tablet orally twice daily for 10 days.
From the Research
Essential Treatment for C. diff Patients
The essential treatment for Clostridioides difficile (C. diff) patients involves several approaches, including:
- Antibiotic treatment: Oral vancomycin is proposed as the first choice when antibiotic treatment for C. diff is necessary 3.
- Alternative therapies: Fidaxomicin is a good alternative, especially in patients at risk of relapse 3, 4.
- Faecal microbiota transplantation (FMT): FMT remains the primary therapy for multiple recurrent C. diff infection 3, 5, 6.
- Combination therapy: Vancomycin combined with FMT may be considered for patients with recurrent C. diff infection 3, 6.
Treatment Options for Recurrent C. diff Infection
For recurrent C. diff infection, the following treatment options are available:
- Fidaxomicin: Reduces the risk of recurrent C. diff infection compared with vancomycin 4, 7.
- Rifaximin: May be considered as an alternative treatment option 3, 7.
- Faecal microbiota transplantation: Likely leads to a large increase in resolution of recurrent C. diff infection compared to alternative treatments such as antibiotics 5.
- Vancomycin: May be used as a standard treatment regimen, but FMT via colonoscopy has been shown to be more effective 6.
Considerations for Treatment
When considering treatment for C. diff patients, the following factors should be taken into account:
- Recurrence rate: Up to 20% of patients may experience recurrence of C. diff infection 3.
- Antibiotic resistance: The use of antibiotics may further exacerbate dysbiosis and contribute to recurrence 5.
- Patient population: Immunocompromised patients may require special consideration, as the efficacy and safety of FMT in this population are not well established 5.