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

From the Guidelines

The treatment for Clostridioides difficile (C. diff) infection should be guided by the clinical presentation, with fidaxomicin 200 mg given twice daily for 10 days being the preferred treatment for an initial episode, and vancomycin or fidaxomicin being considered for recurrent episodes, 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.

Treatment Approach

The approach to treating C. diff infection involves:

• For an initial episode, fidaxomicin 200 mg twice daily for 10 days is preferred, with vancomycin 125 mg four times daily for 10 days being an acceptable alternative 1.
• For a first recurrence, fidaxomicin 200 mg twice daily for 10 days or vancomycin in a tapered and pulsed regimen are recommended 1.
• For multiple recurrences, options include vancomycin in a tapered and pulsed regimen, fidaxomicin, or vancomycin followed by rifaximin, with fecal microbiota transplantation considered for those who have failed appropriate antibiotic treatments 1.

Key Considerations

• The choice of treatment should be based on the severity of the infection, with fulminant cases requiring more aggressive treatment, such as vancomycin 500 mg four times daily by mouth or by nasogastric tube, and possibly intravenous metronidazole 1.
• Patients should be advised to stay well-hydrated, avoid anti-diarrheal medications, and practice strict hand hygiene with soap and water 1.
• Probiotics may be considered as an adjunct therapy to help restore gut flora, although the evidence for their use is limited 1.

Adjunctive Treatments

• Bezlotoxumab 10 mg/kg given intravenously once during administration of standard of care antibiotics may be considered for patients at high risk of recurrence, although its use is limited by the availability of resources and logistics for intravenous administration 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 treatment for Clostridioides difficile (C. diff) infection is fidaxomicin (DIFICID), which 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.
• The recommended dosage for pediatric patients is based on weight, with dosages ranging from 80 mg to 200 mg administered orally twice daily for 10 days 2.

From the Research

Treatment Options for Clostridioides difficile (C. diff) Infection

• The primary treatment for C. diff infection includes antibiotics such as vancomycin and fidaxomicin 3, 4.
• Vancomycin is proposed as the first choice for antibiotic treatment of C. diff infection, with fidaxomicin as a good alternative, especially in patients at risk of relapse 3.
• Fecal microbiota transplantation is effective and safe for the treatment of recurrent C. diff infection, and is often used in combination with vancomycin 3, 4, 5.
• Bezlotoxumab, a monoclonal antibody, is used to prevent recurrent C. diff infection, and has shown promising results in clinical trials 4, 6.
• Other emerging treatment approaches include the use of bacteriophages, endolysins, and tailocins to directly kill C. diff, as well as restoration of microbiota composition and function using probiotics and defined microbial mixtures 6.

Treatment Response and Recurrence

• Fidaxomicin has been shown to be effective in treating C. diff infection in patients with inflammatory bowel disease, with a response rate of 60.6% 5.
• However, recurrence rates remain high, with 30% of patients experiencing a recurrence after fidaxomicin treatment 5.
• Fecal microbiota transplantation is often used as a salvage therapy for patients who do not respond to antibiotic treatment, and has been shown to be effective in resolving C. diff infection in these patients 5.

Emerging Therapies

• Several emerging therapies are being developed to treat C. diff infection, including investigational antibiotics, monoclonal antibodies, vaccines, and microbe-based approaches 6, 7.
• These therapies aim to address the limitations of current treatments, including poor efficacy and high recurrence rates, and offer promising alternatives for the prevention and treatment of C. diff infection 6, 7.