From the Guidelines
The main treatment for Clostridioides difficile (C. diff) infection is fidaxomicin 200 mg given twice daily for 10 days, 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 Options
The treatment of C. diff infection depends on the severity and recurrence status of the infection.
- For initial non-severe cases, fidaxomicin 200 mg twice daily for 10 days is the preferred treatment, with vancomycin 125 mg four times daily for 10 days as an alternative 1.
- For severe infections, the same regimens are used, with vancomycin being the preferred treatment for fulminant C. diff (hypotension, shock, ileus) at a dose of 500 mg four times daily plus intravenous metronidazole 500 mg every 8 hours 1.
- For first recurrence, fidaxomicin 200 mg given twice daily for 10 days is the preferred treatment, with vancomycin in a tapered and pulsed regimen as an alternative 1.
- For multiple recurrences, options include vancomycin in a tapered and pulsed regimen, fidaxomicin extended regimen, or fecal microbiota transplantation, with fidaxomicin 200 mg given twice daily for 10 days being a preferred treatment option 1.
Rationale
The 2021 guidelines recommend fidaxomicin as the preferred treatment for initial and recurrent C. diff infections due to its efficacy and safety profile 1. Vancomycin is also an effective treatment option, but its use is limited by the risk of resistance and recurrence 1. Fecal microbiota transplantation is a viable option for patients with multiple recurrences, but its use is limited by the availability of donors and the risk of transmission of infectious agents 1.
Key Considerations
- The treatment of C. diff infection should be individualized based on the severity and recurrence status of the infection, as well as the patient's underlying medical conditions and risk factors for recurrence 1.
- The use of bezlotoxumab, a monoclonal antibody against C. diff toxin B, may be considered for patients with a high risk of recurrence, but its use is limited by the risk of congestive heart failure and the need 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 main treatment for Clostridioides difficile (C. diff) infection is fidaxomicin (DIFICID), which is indicated for the treatment of C. difficile-associated diarrhea (CDAD) in adult and pediatric patients aged 6 months and older 2.
- Key points:
- Fidaxomicin is used to treat CDAD.
- It is indicated for adult and pediatric patients aged 6 months and older.
- The recommended dosage for adults is one 200 mg tablet orally twice daily for 10 days 2.
From the Research
Treatment Options for Clostridioides difficile (C. diff) Infection
The main treatment for C. diff infection depends on the severity of the infection and whether it is an initial or recurrent episode.
- For milder cases of C. diff infection, oral metronidazole is recommended 3.
- For more severe cases, oral vancomycin or fidaxomicin are recommended 3, 4.
- In cases of recurrent C. diff infection, treatment options include:
- FMT has been shown to be highly efficacious in treating recurrent C. diff infection, with higher success rates than vancomycin or fidaxomicin 6, 5, 7.
- Novel approaches, including new antibiotics and immunotherapy, are also being explored as potential treatments for C. diff infection 3, 6.
Treatment of Recurrent C. diff Infection
Recurrent C. diff infection is a significant concern, with rates of 20-30% after a primary infection and 60% after three or more episodes 6.
- Treatment of recurrent C. diff infection involves a choice of therapy that is different from the antibiotic used in the primary episode 6.
- FMT is a reasonable treatment option for patients who have had multiple recurrent episodes and have received appropriate antibiotic therapy for at least three of the episodes 4.
- Standardized microbiome-based therapies, such as SER-109 and RBX2660, have also shown promise in reducing the recurrence rate of C. diff infection 6.