What is the treatment for recurrent Clostridioides difficile (C. diff) infection?

From the Guidelines

The most effective treatment for recurrent Clostridioides difficile infection is fidaxomicin, which is recommended over vancomycin due to its lower recurrence rates, as suggested by the 2021 focused update guidelines by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 1.

Treatment Options

• For a first recurrence, fidaxomicin 200 mg twice daily for 10 days is recommended due to its lower recurrence rates.
• Alternatively, vancomycin can be used as a standard 10-day course (125 mg four times daily) or as a tapered and pulsed regimen (starting at 125 mg four times daily, then gradually reducing frequency over several weeks) 1.
• For multiple recurrences, options include extended vancomycin pulsed regimens, vancomycin followed by rifaximin, or fidaxomicin extended regimens.

Fecal Microbiota Transplantation

• Fecal microbiota transplantation (FMT) is highly effective for patients with multiple recurrences who have failed appropriate antibiotic treatments, with success rates of 80-90%, as recommended by the 2017 update guidelines by the IDSA and SHEA 1.

Additional Considerations

• Bezlotoxumab, a monoclonal antibody against C. difficile toxin B, may be added to antibiotic therapy in high-risk patients to prevent further recurrences.
• Recurrent C. diff infections occur because antibiotics disrupt the normal gut microbiome, allowing C. difficile spores to germinate and produce toxins.
• Treatment strategies aim to eliminate the pathogen while restoring healthy gut flora to prevent further recurrences.

Key Recommendations

• The 2021 focused update guidelines by the IDSA and SHEA suggest fidaxomicin as the preferred treatment option for recurrent CDI episodes, due to its lower recurrence rates 1.
• The 2017 update guidelines by the IDSA and SHEA recommend FMT for patients with multiple recurrences who have failed appropriate antibiotic treatments 1.

From the FDA Drug Label

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.

In two trials, Vancomycin Hydrochloride Capsules 125 mg orally four times daily for 10 days was evaluated in 266 adult subjects with C. difficile-associated diarrhea (CDAD)

The treatment for recurrent Clostridioides difficile (C. diff) infection includes:

• Vancomycin 125 mg orally four times daily for 10 days 2
• Fidaxomicin for the treatment of C. difficile-associated diarrhea (CDAD) in adult and pediatric patients aged 6 months and older 3 Key points:
• Vancomycin and fidaxomicin are used to treat CDAD
• The dosage and duration of treatment may vary depending on the severity of the infection and the patient's response to treatment
• It is essential to use these antibiotics only to treat infections proven or strongly suspected to be caused by C. difficile to reduce the development of drug-resistant bacteria 3

From the Research

Treatment Options for Recurrent C. diff Infection

The treatment of recurrent Clostridioides difficile (C. diff) infection is a challenging task, and various options are available. Some of the treatment options include:

• Vancomycin: a commonly used antibiotic for the treatment of C. diff infection 4
• Fidaxomicin: a new antibiotic with selected action on C. difficile and limited effect on microflora 5
• Fecal microbiota transplantation (FMT): a promising therapeutic option for antibiotic-resistant recurrent C. difficile infections (rCDIs) 6, 7, 8
• Monoclonal antibodies directed against C. difficile toxins: a new, promising approach for the treatment of recurrent cases 5
• Vaccination: a potential additional weapon against C. diff infection 5

Efficacy of Fecal Microbiota Transplantation

Fecal microbiota transplantation (FMT) has shown promising results in the treatment of recurrent C. diff infection. Studies have demonstrated that:

• FMT can lead to a large increase in the resolution of recurrent C. diff infection compared to alternative treatments such as antibiotics 8
• FMT may result in a reduction in serious adverse events, although the evidence is not conclusive 8
• FMT may also result in a reduction in all-cause mortality, although the number of events is small and the evidence is not conclusive 8

Comparison of Treatment Options

Comparing the efficacy of different treatment options for recurrent C. diff infection, studies have found that:

• FMT is the most efficacious treatment option, particularly in comparison with commonly used antibiotics such as vancomycin or fidaxomicin 7
• Vancomycin and fidaxomicin are also effective treatment options, although they may not be as effective as FMT in preventing recurrence 5, 4

Special Considerations

In certain populations, such as pediatric patients with cystic fibrosis, FMT may be a promising treatment option for recurrent C. diff infection 6. However, more research is needed to fully understand the efficacy and safety of FMT in these populations.