Should a patient with type 7 stool, known to be a Clostridioides difficile (C. diff) carrier, with a current toxin-positive sample, receive treatment for C. diff infection?

From the Guidelines

This patient with type 7 stool who is a known C. difficile carrier but now has a toxin-positive sample should be treated for active C. difficile infection (CDI) with oral vancomycin 125 mg four times daily for 10 days, as recommended by the most recent and highest quality study 1. The presence of toxin in a symptomatic patient (with diarrhea) represents active disease rather than mere colonization.

Key Considerations

• The patient's current toxin-positive sample indicates active infection, which requires treatment to prevent complications such as pseudomembranous colitis, toxic megacolon, or perforation.
• The treatment approach should prioritize the patient's symptoms and severity of infection, with oral vancomycin being the first-line treatment for mild to moderate CDI.
• For severe infection, the same vancomycin regimen is recommended, while for fulminant cases, vancomycin 500 mg four times daily plus intravenous metronidazole 500 mg every 8 hours should be considered.

Additional Management

• Discontinuing unnecessary antibiotics if possible
• Implementing contact precautions with a private room
• Proper hand hygiene with soap and water (alcohol-based sanitizers are less effective against C. difficile spores)
• Environmental cleaning with sporicidal agents
• Monitoring for clinical improvement within 48-72 hours of treatment initiation

Treatment Rationale

The treatment rationale is based on the most recent and highest quality study 1, which recommends oral vancomycin as the first-line treatment for mild to moderate CDI.

• Fidaxomicin 200 mg twice daily for 10 days may be a valid alternative to vancomycin in patients with CDI, particularly those at high risk for recurrence.
• Fecal microbiota transplantation (FMT) is an effective option for patients with multiple CDI recurrences who have failed appropriate antibiotic treatments.
• Coadjuvant treatment with monoclonal antibodies (bezlotoxumab) may prevent recurrences of CDI, particularly in patients with CDI due to the 027 epidemic strain, in immunocompromised patients, and in patients with severe CDI.

From the FDA Drug Label

DIFICID is indicated in adult and pediatric patients aged 6 months and older for the treatment of C. difficile-associated diarrhea (CDAD). To reduce the development of drug-resistant bacteria and maintain the effectiveness of DIFICID and other antibacterial drugs, DIFICID should be used only to treat infections that are proven or strongly suspected to be caused by C. difficile.

The patient has a current toxin-positive sample and is a known C. diff carrier with type 7 stool, indicating a high likelihood of C. difficile-associated diarrhea. Given this information, treatment for C. diff infection is warranted. Fidaxomicin is indicated for the treatment of C. difficile-associated diarrhea in adult and pediatric patients aged 6 months and older. Therefore, the patient should receive treatment for C. diff infection with fidaxomicin. 2 2

From the Research

Treatment Approach for C. diff Infection

The patient in question has type 7 stool, is a known C. diff carrier, and has a current toxin-positive sample. Considering this information, the treatment approach can be outlined as follows:

• The patient should receive treatment for C. diff infection, as the current toxin-positive sample indicates an active infection 3, 4, 5, 6.
• The treatment options for C. diff infection include fidaxomicin, vancomycin, and metronidazole 3, 4, 5, 6.
• Fidaxomicin is a preferred treatment option, especially for patients at risk of relapse, due to its lower rate of recurrence compared to vancomycin 3, 4, 5.
• Vancomycin is also an effective treatment option, and its combination with fecal microbiota transplantation is recommended for multiple recurrent C. diff infections 4, 5.
• Metronidazole is not recommended as a first-line treatment due to its lower efficacy and higher rate of recurrence compared to fidaxomicin and vancomycin 4, 5.

Considerations for Treatment

When deciding on a treatment approach, the following factors should be considered:

• The patient's medical history, including any previous C. diff infections and treatments 4, 5, 6.
• The severity of the current infection, including the presence of any complications such as pseudomembranous colitis or toxic megacolon 6.
• The patient's risk of recurrence, including factors such as age, underlying medical conditions, and previous C. diff infections 3, 4, 5.
• The availability and cost of treatment options, including fidaxomicin, vancomycin, and fecal microbiota transplantation 4, 5.