What are the next steps for a patient with a history of bowel resection who was previously treated with vancomycin (Vancomycin) 250 mg twice daily (BID) for 10 days for Clostridioides difficile (C-diff) infection, but is now experiencing recurrent diarrhea?

Management of Recurrent C. difficile Infection After Vancomycin Treatment

For a patient with a history of bowel resection who has recurrent diarrhea after completing vancomycin treatment for C. difficile infection, the next step should be to confirm recurrent C. difficile infection and then initiate fidaxomicin 200 mg twice daily for 10 days. 1, 2

Diagnostic Confirmation

First, confirm that the symptoms represent recurrent C. difficile infection:

• Verify acute-onset, clinically significant diarrhea (≥3 unformed stools in 24 hours)
• Obtain stool testing using:
  • Highly sensitive test (nucleic acid amplification or glutamate dehydrogenase) combined with
  • Highly specific test (toxin enzyme immunoassay)
• Rule out alternative diagnoses, especially important in patients with bowel resection who may have other causes of diarrhea 1

Treatment Algorithm for Confirmed Recurrent CDI

First-line Treatment

• Fidaxomicin 200 mg orally twice daily for 10 days 2, 3
  • Preferred over vancomycin for recurrent cases due to lower recurrence rates (HR 0.67,95% CI 0.50-0.90) 4
  • Can be administered with or without food 3

Alternative Treatment (if fidaxomicin unavailable)

• Vancomycin 125 mg orally four times daily for 10 days 2, 5
  • Note: Higher doses (500 mg) have not shown additional benefit over 125 mg dosing 5

Prevention of Further Recurrence

After completing antibiotic treatment, consider:

1. Fecal microbiota-based therapy upon completion of standard antibiotics 1

   • Indicated after second recurrence (third episode) or in high-risk patients
   • Options include:
     • Conventional fecal microbiota transplant (FMT)
     • FDA-approved products: fecal microbiota live-jslm or fecal microbiota spores live-brpk
   • Timing: Should be given 1-3 days after completing antibiotics
     • If bowel purge is given: FMT can be given 1 day after stopping antibiotics
     • If no bowel purge: 3 days off antibiotics is recommended 1

2. Vancomycin taper/pulse regimen (if fecal microbiota-based therapy not available)

   • Though recent mouse model studies question the efficacy of pulse dosing 6

Special Considerations for Bowel Resection Patients

• Patients with bowel resection may have altered gut microbiota and potentially higher risk for recurrence
• Monitor closely for signs of severe disease (hypotension, shock, ileus, megacolon)
• Assess for complications related to bowel anatomy that might affect drug absorption

Infection Control Measures

• Strict hand hygiene with soap and water (not alcohol-based sanitizers)
• Contact precautions and environmental cleaning
• Discontinue any unnecessary antibiotics that may have triggered the infection 2

Monitoring Response

• Expect improvement within 2-3 days of treatment initiation
• If no improvement within 48-72 hours, reassess severity and consider alternative diagnoses
• Avoid antiperistaltic agents and opiates as they can mask symptoms and potentially worsen the condition 2

The evidence strongly supports using fidaxomicin for recurrent C. difficile infection, followed by consideration of fecal microbiota-based therapy to prevent further recurrences, especially in high-risk patients like those with bowel resection.