Recurrence Risk of Clostridioides difficile Infection
Yes, C. difficile infection has a high likelihood of recurrence, with approximately 25% of patients treated with vancomycin experiencing at least one additional episode. 1
Risk of Recurrence
- Approximately 25% of patients treated for CDI with vancomycin will experience at least one recurrent episode 1
- Recurrence can be due to either relapse with the same strain or reinfection with a different strain, though clinically these cannot be distinguished and management is the same 1
- Recurrent CDI can occur within 30 days of treatment completion 2
Risk Factors for Recurrence
Patient-Related Factors
- Advanced age (>65 years) significantly increases recurrence risk (RR 1.5) 3, 2
- Impaired immune response to C. difficile toxins (particularly in elderly patients) 2
- History of previous CDI recurrences (each recurrence increases risk of subsequent episodes) 1, 2
- Severe underlying disease (as measured by Horn index) 2
- Hypoalbuminemia (<2.5 g/dL) impairs binding of C. difficile toxins 1
Treatment-Related Factors
- Continued use of antibiotics for non-C. difficile infections during or after CDI treatment 1, 2
- Continued use of proton pump inhibitors (RR 1.3) 1, 3
- Choice of initial treatment (fidaxomicin has lower recurrence rates compared to vancomycin) 1, 4
Clinical Predictors
- Increased number of unformed bowel movements (≥10 in 24 hours) 4
- Elevated serum creatinine (≥1.2 mg/dL) 4
- Prior episodes of CDI 4
Treatment Considerations to Reduce Recurrence
First Recurrence Treatment Options
- Oral vancomycin as a tapered and pulsed regimen rather than a standard 10-day course 1
- Fidaxomicin 10-day course rather than standard vancomycin course (reduces second recurrence from 35.5% to 19.7%) 1
- Standard 10-day vancomycin course if metronidazole was used for initial episode 1
Multiple Recurrences Treatment Options
- Vancomycin in tapered and pulsed regimen (e.g., 125 mg 4 times daily for 10-14 days, then 125 mg twice daily for 7 days, then 125 mg daily for 7 days, then 125 mg every 2-3 days for 2-8 weeks) 1
- Standard vancomycin course followed by rifaximin (though limited evidence) 1
- Fidaxomicin (though limited evidence in multiple recurrences) 1
- Fecal microbiota transplantation for patients with multiple recurrences who have failed appropriate antibiotic treatments 1, 5
Important Clinical Considerations
- Recurrent episodes tend to be less severe than initial episodes (47% severe for initial episodes vs. 31% for first recurrences) 1
- Despite being less severe, recurrences significantly increase healthcare costs, length of hospital stay, and risk of readmission 1
- Metronidazole should not be used for recurrent CDI due to lower response rates and risk of cumulative neurotoxicity with long-term use 1
- For patients requiring antibiotics shortly after CDI treatment, consider prophylactic low-dose vancomycin (125 mg daily) or fidaxomicin (200 mg daily) during the antibiotic course, though evidence is limited 1
- Probiotics have shown some promise but none has demonstrated significant and reproducible efficacy in controlled clinical trials 1