From the Guidelines
The first line treatment for Clostridioides difficile (C-diff) infection is fidaxomicin 200 mg given twice daily for 10 days, as it is the preferred treatment according to the most recent guidelines 1. For mild to moderate cases, oral vancomycin is also an alternative, typically prescribed at 125 mg four times daily for 10 days. The choice of treatment should be based on the severity of the infection, with clinical assessment including white blood cell count, serum creatinine, and presence of complications.
Key Considerations
- Fidaxomicin is preferred for initial episodes of C-diff infection due to its efficacy and lower recurrence rates compared to vancomycin 1.
- Vancomycin remains an acceptable alternative for initial episodes, especially when fidaxomicin is not available 1.
- Metronidazole is considered a second-line agent due to increasing treatment failures and side effects 1.
- Treatment of recurrent C-diff infection may involve vancomycin in a tapered and pulsed regimen, fidaxomicin, or fecal microbiota transplantation for multiple recurrences 1.
Treatment Regimens
- Fidaxomicin: 200 mg twice daily for 10 days for initial episodes 1.
- Vancomycin: 125 mg four times daily for 10 days for initial episodes, with the option for a tapered and pulsed regimen for recurrent cases 1.
- Metronidazole: 500 mg three times daily for 10 days, though its use is now more limited due to side effects and treatment failures 1.
Monitoring and Adjunctive Therapy
- Patients should be monitored for symptom improvement, particularly decreased diarrhea frequency, and should maintain good hydration.
- Probiotics are not officially recommended but may be considered as an adjunct therapy in some cases, though evidence is limited 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 first line treatment for Clostridioides difficile (C-diff) infection is fidaxomicin (PO), as indicated in the drug label for the treatment of C. difficile-associated diarrhea (CDAD) 2.
From the Research
First Line Treatment for C-diff
The first line treatment for Clostridioides difficile (C-diff) infection includes:
- Fidaxomicin: a macrocyclic antibiotic with a narrow spectrum of activity against gram-positive anaerobes, specifically bactericidal against C. difficile 3
- Vancomycin: an antibiotic that is effective against C. difficile, but may have a higher risk of recurrence compared to fidaxomicin 4, 5
Treatment Regimens
Different treatment regimens have been studied, including:
- Fidaxomicin 200 mg orally twice daily for 10 days 3
- Vancomycin 125 mg four times daily for 10 days, followed by a 3-week vancomycin taper and pulse regimen 6
- Extended fidaxomicin regimens, such as 20 days of treatment, or pulsed or tapered dosing 7
Efficacy and Recurrence
Studies have shown that:
- Fidaxomicin is noninferior to vancomycin in the management of mild-to-moderately severe CDI 3
- Fidaxomicin is associated with a lower risk of recurrence compared to vancomycin, with a 31% reduction in risk 5
- The use of concomitant antibiotics during CDI treatment may compromise initial response and durability of response, but fidaxomicin may be more effective than vancomycin in this scenario 4