From the Guidelines
The latest treatment recommendations for Clostridioides difficile (C. diff) infection prioritize fidaxomicin 200 mg twice daily for 10 days as the preferred treatment for initial episodes, and vancomycin in a tapered and pulsed regimen or fidaxomicin for first recurrences, with fecal microbiota transplantation considered for multiple recurrences, as per the 2021 guidelines by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 1. The treatment approach is stratified based on disease severity and recurrence status. For initial non-severe cases, oral vancomycin 125 mg four times daily for 10 days is an alternative option. For severe initial episodes, the same regimens are used, with the addition of intravenous metronidazole 500 mg every 8 hours for fulminant C. diff. Key considerations include:
- Initial episode treatment: fidaxomicin or vancomycin
- First recurrence treatment: vancomycin in a tapered and pulsed regimen or fidaxomicin
- Multiple recurrences: fecal microbiota transplantation after appropriate antibiotic treatment
- High-risk patients: consideration of bezlotoxumab, a monoclonal antibody against C. diff toxin B, in addition to standard antibiotic treatment These recommendations aim to effectively clear the infection while minimizing disruption to the gut microbiome, which is crucial for preventing recurrences, as supported by the latest guidelines 1 and recent studies on fecal microbiota transplantation 1.
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). The latest treatment recommendation for C. difficile is fidaxomicin (PO) for adult and pediatric patients aged 6 months and older, as indicated in the drug label 2.
- Key points:
- Fidaxomicin is used to treat C. difficile-associated diarrhea (CDAD)
- It is indicated for patients aged 6 months and older
- The drug should be used only to treat infections proven or strongly suspected to be caused by C. difficile 2
From the Research
Treatment Recommendations for C. difficile Infection
The latest treatment recommendations for C. difficile infection (CDI) are as follows:
- Vancomycin and fidaxomicin are recommended as first-line therapy for most cases of CDI 3, 4, 5.
- Metronidazole should only be used for mild-to-moderate disease in younger patients with no or few risk factors for recurrence 4, 5.
- Bezlotoxumab infusion may be considered as an adjunctive therapeutic strategy for recurrent CDI in patients with several risk factors for recurrence 4.
- Faecal microbiota transplantation (FMT) should be offered to patients with frequently recurring CDI 3, 4, 5.
Comparison of Treatment Outcomes
Studies have compared the efficacy of different antibiotic regimens for the treatment of CDI:
- Fidaxomicin was superior to metronidazole, vancomycin, or their combination for sustained clinical response and prevention of recurrent CDI in the initial episode, first recurrence, and non-severe cases 6.
- Fidaxomicin had a similar treatment outcome to vancomycin in the oral treatment of severe CDI 6.
- However, another study found that fidaxomicin was inferior to metronidazole for recurrent CDI 7.
Resistance Profile
The resistance profile of C. difficile to vancomycin and metronidazole has been studied: