From the Guidelines
For high-risk patients with Clostridioides difficile (C. diff) infection, prophylactic treatment should focus on prevention strategies such as strict hand hygiene, contact precautions, and antimicrobial stewardship to limit unnecessary antibiotic use, rather than prophylactic antibiotics. When antibiotics are necessary for other infections in these high-risk patients, consider using antibiotics with lower C. difficile risk such as tetracyclines, aminoglycosides, macrolides, or narrow-spectrum beta-lactams when clinically appropriate, as suggested by general principles of antimicrobial stewardship 1. Some key points to consider in managing or preventing C. diff infection in high-risk patients include:
- The use of oral vancomycin prophylaxis at 125 mg once daily during and for several days after the antibiotic course for patients with a history of recurrent C. difficile infection who require antibiotics, though this approach is not universally recommended and should be considered on a case-by-case basis 1.
- Bezlotoxumab, a monoclonal antibody against C. difficile toxin B, may be considered for patients with multiple risk factors for recurrent infection, administered as a single 10 mg/kg IV infusion, with caution in patients with a history of congestive heart failure 1.
- Probiotics have mixed evidence but some formulations containing Lactobacillus species or Saccharomyces boulardii might provide modest benefit when started with antibiotic therapy, aiming to reduce the disruption of normal gut microbiota that creates an environment favorable for C. difficile proliferation. In the context of real-life clinical medicine, prioritizing strategies that minimize the risk of C. difficile infection while treating other infections is crucial, and the approach should be individualized based on the patient's risk factors and medical history, as outlined in the guidelines by the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) 1.
From the Research
Prophylactic Treatment for High-Risk Patients with C. diff Infection
- The use of fidaxomicin has been shown to be effective in treating C. difficile infection, with a lower rate of recurrence compared to vancomycin 2.
- Vancomycin is also a commonly used treatment for C. difficile infection, and has been shown to be effective in clinical trials 3, 4.
- For high-risk patients, such as the elderly, fidaxomicin may be a good alternative to vancomycin due to its lower rate of recurrence 2, 5.
- Saccharomyces boulardii, a probiotic, has been shown to be effective in preventing recurrent C. difficile infection, and may be used as an adjunctive treatment 6, 5.
- Fecal microbiota transplantation has also been shown to be effective in treating recurrent C. difficile infection, and may be considered for patients who have failed other treatments 4.
Treatment Options
- Fidaxomicin: 200 mg twice daily for 10 days 2
- Vancomycin: 125 mg four times daily for 10 days 2, 3, 4
- Saccharomyces boulardii: dosage varies, but typically 500-1000 mg per day 6, 5
- Fecal microbiota transplantation: via upper or lower gastrointestinal route, or by capsules 4
Patient Considerations
- Elderly patients may be at increased risk of morbidity and mortality from C. difficile infection, and may require closer monitoring and more aggressive treatment 5.
- Patients with recurrent C. difficile infection may require alternative treatments, such as fidaxomicin or fecal microbiota transplantation 3, 4.