What is the recommended treatment for the first recurrence of Clostridioides (C.) difficile infection?

From the Guidelines

For the first recurrence of Clostridioides difficile infection, fidaxomicin 200 mg given twice daily for 10 days is the preferred treatment, as it has shown lower recurrence rates compared to vancomycin, according to the 2021 focused update guidelines by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 1. The guidelines suggest that fidaxomicin can be given for 10 days or for 5 days followed by once every other day for 20 days for the first recurrence. Alternatively, vancomycin can be used, either as a standard course of 125 mg four times daily by mouth for 10 days or in a tapered and pulsed regimen, which may be considered based on patient-specific factors and resource availability 1. It's also important to note that for patients who were initially treated with metronidazole for their first episode, switching to vancomycin or fidaxomicin is recommended rather than repeating metronidazole therapy, due to the higher efficacy of these treatments in preventing further recurrences. Key considerations in managing the first recurrence of C. difficile infection include:

• Using fidaxomicin or vancomycin as the primary treatment options due to their effectiveness in reducing recurrence rates 1.
• Avoiding the use of metronidazole for recurrences, especially if it was used for the initial episode, due to its lower efficacy in preventing further recurrences.
• Ensuring patients complete the full course of antibiotics, even if symptoms improve quickly, to minimize the risk of further recurrence.
• Advising patients to stay well-hydrated and avoid anti-motility agents, which can worsen the condition. The choice between fidaxomicin and vancomycin should be based on the clinical presentation, patient preferences, and available resources, with fidaxomicin being suggested for its potential to reduce recurrence rates, as indicated by the guidelines 1.

From the Research

Treatment Options for First Recurrence of C. difficile Infection

The treatment for the first recurrence of Clostridioides (C.) difficile infection is a critical aspect of managing this condition. Several studies have investigated the efficacy of different treatment options.

• Fidaxomicin vs Vancomycin: A study published in 2012 2 compared fidaxomicin and vancomycin in treating CDI. The results showed that fidaxomicin was similar to vancomycin in achieving a clinical response at the end of therapy but superior in preventing a second recurrence within 28 days.
• Antibiotic Regimens: A 2022 study 3 described a randomized, double-blind comparison of three antibiotic regimens for patients with a first or second recurrence of CDI. The study aimed to determine the optimal treatment among fidaxomicin, vancomycin, and a vancomycin taper and pulse regimen.
• Update of Treatment Algorithms: An update on treatment algorithms for CDI published in 2018 4 suggested that oral vancomycin will become the first choice when antibiotic treatment for CDI is necessary, with fidaxomicin as a good alternative, especially in patients at risk of relapse.
• Fecal Microbiota Transplantation: A 2019 study 5 found that fecal microbiota transplantation (FMT) was superior to fidaxomicin and vancomycin for treatment of recurrent CDI. The study showed that FMT resulted in higher combined clinical resolution and negative results from a polymerase chain reaction test for CD toxin.
• Fidaxomicin Efficacy: A 2014 study 6 investigated the efficacy of fidaxomicin in a human gut model and found that it successfully treated simulated primary and recurrent CDI, with a minimal effect on the microflora.

Key Findings

• Fidaxomicin is effective in treating CDI and preventing recurrence 2, 6.
• Vancomycin is also effective, but may have a higher recurrence rate compared to fidaxomicin 2.
• Fecal microbiota transplantation is a promising treatment option for recurrent CDI, with superior results compared to fidaxomicin and vancomycin 5.
• The choice of treatment should be based on individual patient factors, including the risk of relapse and the presence of underlying conditions 4.