From the Guidelines
Clostridioides difficile (C. diff) colitis should be treated with oral vancomycin 125 mg four times daily for 10 days or fidaxomicin 200 mg twice daily for 10 days for mild to moderate first episodes, with consideration of fecal microbiota transplantation for multiple recurrences, as recommended by the most recent and highest quality study 1.
Diagnosis and Treatment
The diagnosis of C. diff colitis is typically made based on symptoms and stool tests. Treatment depends on the severity of the infection, but generally involves stopping the offending antibiotic if possible and starting specific antimicrobial therapy.
- For mild to moderate first episodes, oral vancomycin 125 mg four times daily for 10 days or fidaxomicin 200 mg twice daily for 10 days is recommended 1.
- For severe cases, oral vancomycin 125 mg four times daily for 10 days is preferred 1.
- In fulminant cases with hypotension or shock, higher doses of vancomycin (500 mg four times daily) plus intravenous metronidazole 500 mg every 8 hours may be needed, with surgical consultation for possible colectomy if clinical deterioration occurs 2.
Recurrent Infections
Recurrent infections are common (20-30% of cases) and may require extended vancomycin tapers, fidaxomicin, or consideration of fecal microbiota transplantation for multiple recurrences 3.
- A first recurrence of CDI may be treated with oral vancomycin, vancomycin followed by a tapered and pulsed regimen, or fidaxomicin 4.
- Second or subsequent CDI recurrences may be treated with oral vancomycin as a tapered and pulsed-dose regimen, fidaxomicin, or fecal microbiota transplantation 1.
Prevention
Prevention focuses on proper hand hygiene, contact precautions, environmental cleaning, and antibiotic stewardship 1.
- C. diff produces toxins that damage the intestinal lining, causing inflammation and symptoms ranging from mild diarrhea to life-threatening pseudomembranous colitis, making prompt diagnosis and appropriate treatment essential.
Fecal Microbiota Transplantation
Fecal microbiota transplantation is recommended for patients with multiple recurrences of CDI who have failed appropriate antibiotic treatments, with a high degree of success in correcting intestinal dysbiosis and resolving CDI symptoms 3.
- Potential candidates for FMT include patients with multiple recurrences of CDI who have failed to resolve their infection despite treatment attempts with antibiotic agents targeting CDI 3.
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).
Patient Information
What is DIFICID DIFICID is an antibiotic medicine used to treat an infection called Clostridioides difficile-associated diarrhea (CDAD) in adults and children 6 months of age and older.
The diagnosis of Clostridioides difficile (C. diff) colitis is not directly addressed in the provided drug labels. The treatment for C. difficile-associated diarrhea (CDAD) is fidaxomicin (DIFICID) tablets or oral suspension, which is indicated in adult and pediatric patients aged 6 months and older [5][6]7.
From the Research
Diagnosis of Clostridioides difficile (C. diff) Colitis
- The diagnosis of C. diff colitis can be made using a multi-step approach, with a highly sensitive initial rapid test such as the enzyme immunoassay (EIA) for glutamate dehydrogenase (GDH) or nucleic acid amplification testing (NAAT), followed by confirmatory testing with one of the above two tests or EIA toxin A/B, which has high specificity 8.
- The updated Czech guidelines recommend using orally administered fidaxomicin or vancomycin as the drug of choice for hospitalized patients, while metronidazole can also be used for outpatients with a mild first episode of C. difficile infection 9.
Treatment of Clostridioides difficile (C. diff) Colitis
- The treatment of C. diff colitis varies based on the severity of the disease, with vancomycin recommended as first-line therapy for an initial episode of mild/moderate or severe CDI, and consideration of fidaxomicin for patients at particularly high risk for recurrence 8.
- For non-severe recurrent disease, the initial treatment regimen should be repeated, while subsequent episodes are more appropriately treated with a tapered and pulsed dose of vancomycin, fidaxomicin, or fecal microbiota transplantation 8.
- The updated Czech guidelines recommend reducing the duration of antibiotic treatment to 5 days for fidaxomicin or 6-7 days for vancomycin if the patient's response to treatment is good and there are no complications 9.
- For fulminant C. difficile colitis, treatment with oral fidaxomicin ± tigecycline i.v. is recommended, with consideration of colectomy as a last resort if sepsis develops 9.
- Other treatment options include metronidazole, which is recommended for initial mild to moderate episodes or first recurrence, and Saccharomyces boulardii, which is the only probiotic that has shown efficacy in CDI 10, 11.
Recurrent Clostridioides difficile (C. diff) Colitis
- Recurrent CDI is a challenge to treat, with no single effective therapy currently existing, and treatments including antibiotics, adjunct probiotics, fecal microbiota transplant, and immune approaches 10.
- For first recurrence, fidaxomicin or vancomycin is administered with a subsequent fecal microbiota transplant (FMT) from a healthy donor, while for second or subsequent recurrence, administration of fidaxomicin is of little benefit, and the therapy of choice is oral vancomycin and subsequent FMT 9.
- Prolonged vancomycin or fidaxomicin taper and pulse treatment is appropriate only when FMT cannot be performed 9.