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

Treatment of Clostridioides difficile Bacteremia

Oral vancomycin 125 mg four times daily for 10 days is the first-line treatment for Clostridioides difficile bacteremia, with fidaxomicin 200 mg twice daily for 10 days as an alternative first-line option. 1

Diagnostic Approach

When C. difficile bacteremia is suspected:

1. Obtain blood cultures from both peripheral vein and central venous catheter (if present)
2. Perform stool testing for C. difficile toxins
3. Complete blood count, renal function, and electrolytes should be evaluated
4. Consider endoscopy or colonoscopy with biopsy in moderate to severe cases

Treatment Algorithm

First-Line Treatment Options

• Oral vancomycin 125 mg four times daily for 10 days 1

  • Superior clinical cure rates compared to metronidazole
  • Recommended by IDSA/SHEA guidelines

• Fidaxomicin 200 mg twice daily for 10 days 1

  • Particularly beneficial for patients over 65 years
  • Associated with lower recurrence rates compared to vancomycin
  • Consider for patients at high risk for recurrence (elderly, multiple comorbidities, receiving concomitant antibiotics)

For Severe or Fulminant C. difficile Bacteremia

• Oral vancomycin 125-500 mg four times daily 2, 1
• Consider adding IV metronidazole 500 mg every 8 hours 1
• Early surgical consultation for patients with systemic toxicity 2
• Consider diverting loop ileostomy with colonic lavage as an alternative to total colectomy in fulminant cases 2

Important Adjunctive Measures

1. Discontinue unnecessary antibiotics immediately 1

   • This is crucial to reduce treatment failure and recurrence risk

2. If continued antibiotic therapy is required for primary infection:

   • Use antibiotics less frequently implicated with CDI:
     • Parenteral aminoglycosides
     • Sulfonamides
     • Macrolides
     • Tetracycline/tigecycline 2

3. Consider discontinuing proton pump inhibitors if not clinically indicated 2

4. Monitor anticoagulation therapy if applicable:

   • Check INR every 2-3 days during treatment
   • Adjust warfarin dosing as needed 1

Management of Recurrent Infection

• 20-25% of patients experience recurrence 1
• For first recurrence: Use same treatment as initial episode 1
• For multiple recurrences:
  • Vancomycin taper/pulse regimen
  • Fidaxomicin
  • Fecal microbiota transplantation (FMT) after failure of appropriate antibiotic treatments 2, 1
    • Clinical cure rates between 70-90% for recurrent CDI 1
  • Consider bezlotoxumab (monoclonal antibody) as adjunctive therapy to reduce recurrence risk, particularly for:
    • CDI due to the 027 epidemic strain
    • Immunocompromised patients
    • Patients with severe CDI 2, 1

Clinical Pearls and Pitfalls

• Pitfall: Using metronidazole as first-line therapy

  • Vancomycin is superior to metronidazole in all cases of CDI (OR = 0.46,95% CI 0.26–0.80) 1

• Pitfall: Continuing unnecessary antibiotics

  • Certain antibiotics carry higher risk of CDI:
    • Clindamycin (OR 35.31)
    • Fluoroquinolones (OR 30.71)
    • Cephalosporins (OR 19.02) 1

• Pitfall: Repeat testing during or after treatment

  • No additional testing is required during treatment
  • No follow-up testing is recommended after symptom resolution 1

• Pearl: Recognize high-risk patients

  • Age >65 years
  • Concurrent antibiotic use
  • Multiple comorbidities 1

By following this evidence-based approach, clinicians can effectively manage C. difficile bacteremia while minimizing the risk of recurrence and complications.