From the Guidelines
Yes, there is value in a long course of treatment for C. diff (Clostridioides difficile) recurrence.
Treatment Options
- Fidaxomicin is preferred over vancomycin for recurrent CDI, with a suggested standard or extended-pulsed regimen 1.
- Vancomycin in a tapered and pulsed regimen or vancomycin as a standard course are acceptable alternatives for a first CDI recurrence 1.
- For patients with multiple recurrences, vancomycin in a tapered and pulsed regimen, vancomycin followed by rifaximin, and fecal microbiota transplantation are options in addition to fidaxomicin 1.
Fecal Microbiota Transplantation
- Fecal microbiota-based therapies can be considered in patients after the second recurrence (third episode) of CDI or in select patients at high risk of either recurrent CDI or a morbid CDI recurrence 2.
- Fecal microbiota transplantation has shown high rates of treatment success (70-92%) for recurrent CDI, regardless of the route of installation of feces or the preparation of feces 3.
Key Considerations
- The certainty of the evidence for the effect of fidaxomicin on sustained response at 90 days is very low due to imprecision and risk of bias 4.
- Fecal microbiota transplantation should be performed with appropriately screened donor stool, and special testing may be necessary for immunocompromised patients 2.
- The use of fecal microbiota-based therapies in severely immunocompromised adults is not recommended due to the lack of evidence and potential risks 2, 5.
From the FDA Drug Label
In subjects with diarrhea resolution at end-of-treatment with Vancomycin Hydrochloride Capsules, recurrence of CDAD during the following four weeks occurred in 25 of 107 (23%) and 18 of 102 (18%) in Trial 1 and Trial 2, respectively. The answer to whether there is value in a long course of treatment for C. diff (Clostridioides difficile) recurrence is not directly addressed in the provided drug label. The label reports the recurrence rates of CDAD during the four weeks following treatment with vancomycin hydrochloride capsules, but it does not compare the efficacy of different treatment durations. Therefore, no conclusion can be drawn about the value of a long course of treatment for C. diff recurrence based on this information 6.
From the Research
Treatment of C. diff Recurrence
- The use of extended duration vancomycin (EDV) is a common approach for treating recurrent Clostridium difficile infections (rCDI) 7.
- Studies have shown that EDV regimens can be effective in reducing recurrence rates, with success rates ranging from 61% to 100% in case series and 26% to 58% in randomized trials 7.
- Taper and pulse regimens have been found to be more effective than pulse-only regimens, with success rates of 58-100% compared to 26-81% 7.
Comparison of Treatment Regimens
- A study comparing long-duration (LD) and short-duration (SD) oral vancomycin therapy found that LD vancomycin was associated with a lower rate of recurrence (1.8% vs 11.7%) in patients with inflammatory bowel disease (IBD) 8.
- Another study found that a tapered-pulsed fidaxomicin regimen was effective in managing multiple recurrent C. difficile infections, with sustained clinical response rates of 74% and 61% at 30 and 90 days, respectively 9.
Risk Factors and Treatment Strategies
- Advanced age, continuation of other antibiotics, and prolonged hospital stays are epidemiologic risk factors for recurrent CDI 10.
- Current guidelines recommend treating the first recurrent episode with the same agent used for the index episode, and considering vancomycin for severe recurrences 10.
- Other potentially effective strategies for recurrent CDI include vancomycin with adjunctive treatments, such as Saccharomyces boulardii, rifaximin "chaser" therapy, nitazoxanide, fecal transplantation, and intravenous immunoglobulin 10.
Ongoing Research
- A randomized, double-blind comparison of three antibiotic regimens for patients with a first or second recurrence of C. difficile infection is currently underway, aiming to determine the optimal treatment among fidaxomicin, vancomycin, and vancomycin taper and pulse regimens 11.