Should I continue the vancomycin (vancomycin) taper as planned?

Management of Recurrent C. difficile Infection: Continue the Vancomycin Taper

Yes, you should continue the vancomycin taper as planned, as this is the recommended approach for managing recurrent C. difficile infection according to current clinical practice guidelines. 1

Assessment of Your Situation

Based on your description, you appear to be experiencing a recurrent C. difficile infection that is showing some improvement with the current vancomycin taper regimen. You're on day 14 of treatment and about to begin tapering from 4 capsules per day down to 2 capsules per day.

Evidence-Based Treatment Approach

The 2017 IDSA/SHEA guidelines for C. difficile infection provide clear recommendations for managing recurrent infections:

1. For first recurrence of CDI:

   • A prolonged tapered and pulsed vancomycin regimen is recommended if a standard regimen was used for the initial episode (weak recommendation, low quality of evidence) 1
   • The typical regimen includes vancomycin 125 mg 4 times per day for 10–14 days, then 2 times per day for a week, once per day for a week, and then every 2 or 3 days for 2–8 weeks 1

2. For second or subsequent recurrence:

   • Vancomycin in a tapered and pulsed regimen remains a recommended option (weak recommendation, low quality of evidence) 1
   • Fecal microbiota transplantation is recommended after appropriate antibiotic treatments for at least 2 recurrences (i.e., 3 CDI episodes) have failed (strong recommendation, moderate quality of evidence) 1

Specific Recommendations for Your Case

1. Continue the vancomycin taper as prescribed

   • The improvement you're noticing suggests the treatment is working, even if not completely resolved yet
   • Tapering is designed to gradually eliminate C. difficile while allowing restoration of normal gut flora

2. Complete the full course of the taper

   • Premature discontinuation could lead to relapse
   • The extended duration of the taper is specifically designed to prevent recurrence

3. Continue supportive measures

   • Your approach with probiotics (Floragen), yogurt, and kombucha is appropriate as adjunctive therapy
   • Maintaining hydration and a plant-based diet are also beneficial supportive measures

Important Considerations

• Monitoring: Continue to monitor your symptoms during the taper. If symptoms worsen significantly during the taper, contact your healthcare provider.

• Probiotic timing: Take probiotics at least 2 hours apart from vancomycin doses to prevent the antibiotic from killing the beneficial bacteria.

• Future options: If this extended vancomycin taper fails, fidaxomicin or fecal microbiota transplantation would be appropriate next steps to consider, as suggested in your provider's original plan and supported by guidelines 1.

Potential Pitfalls to Avoid

1. Do not discontinue the taper early even if symptoms resolve completely, as this increases risk of recurrence.

2. Avoid unnecessary antibiotics for other conditions during and after treatment, as these can disrupt gut flora and trigger recurrence.

3. Be aware that recent research suggests that while vancomycin taper and pulse regimens are commonly used, they may cause persistent disruption of the microbiota 2. However, this doesn't change the current guideline recommendations, which still support this approach for recurrent infections.

The ID consultation's recommendation aligns with current guidelines, suggesting that referral to infectious disease specialists is typically reserved for patients with 3 or more proven episodes in a few months, after failure of appropriate antibiotic treatments including prolonged vancomycin or fidaxomicin tapers.