What is the effect of Vancomycin on Clostridioides difficile (C. diff) infection?

From the Guidelines

Vancomycin is the preferred treatment for Clostridioides difficile (C. diff) infection, with a standard oral regimen of 125 mg taken by mouth four times daily for 10 days, as recommended by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) in their 2021 focused update guidelines 1.

Key Considerations

• For initial episodes of C. diff infection, vancomycin is the preferred treatment due to its higher cure rates and lower recurrence rates compared to metronidazole 1.
• The standard oral vancomycin regimen is 125 mg taken by mouth four times daily for 10 days, with the option to increase the dose to 500 mg four times daily for severe or complicated infections 1.
• For recurrent C. diff infections, a tapered and pulsed regimen of vancomycin may be used, with a regimen example of 125 mg four times daily for 10-14 days, then twice daily for 7 days, then once daily for 7 days, followed by every 2-3 days for 2-8 weeks 1.

Treatment Approach

• Vancomycin works by inhibiting bacterial cell wall synthesis and is effective against C. diff because it remains in the gut lumen when taken orally, achieving high concentrations at the site of infection.
• During treatment, patients should maintain good hydration, avoid anti-motility agents, and continue probiotics if prescribed.
• Fidaxomicin is an alternative treatment option for C. diff infection, particularly for patients at higher risk of recurrence, with a regimen of 200 mg taken by mouth twice daily for 10 days 1.

Evidence-Based Recommendations

• The IDSA and SHEA guidelines recommend vancomycin as the first-line treatment for C. diff infection, with fidaxomicin as an alternative option 1.
• The guidelines also recommend against the use of metronidazole as a first-line treatment, due to its lower cure rates and higher recurrence rates compared to vancomycin 1.
• The European Society of Clinical Microbiology and Infectious Diseases also recommends vancomycin as the preferred treatment for C. diff infection, with fidaxomicin as an alternative option 1.
• The World Journal of Emergency Surgery recommends vancomycin as the first-line treatment for C. diff infection, with fidaxomicin as an alternative option, and metronidazole as a last resort for patients who cannot access vancomycin or fidaxomicin 1.

From the FDA Drug Label

Vancomycin has been shown to be active against most isolates of the following microorganisms, both in vitro and in clinical infections [see Indications and Usage (1)]. Gram-positive bacteria: Staphylococcus aureus (including methicillin-resistant isolates) associated with enterocolitis. Anaerobic gram-positive bacteria: Clostridium difficile isolates associated with C. difficile associated bacteria.

Vancomycin is effective against C. difficile.

• The drug is used to treat C. difficile-associated diarrhea (CDAD).
• Vancomycin Hydrochloride Capsules 125 mg orally four times daily for 10 days was evaluated in 266 adult subjects with CDAD 2.

From the Research

Vancomycin and C. difficile Infection Treatment

• Vancomycin is a commonly used antibiotic for the treatment of C. difficile infection (CDI) 3, 4, 5, 6.
• The use of vancomycin for CDI treatment is often recommended, especially for patients with severe or recurrent infection 3, 4, 5.
• Fidaxomicin is also used as an alternative to vancomycin for CDI treatment, particularly for patients at risk of relapse 3, 4, 7.
• Vancomycin can be used in combination with fecal microbiota transplantation (FMT) for the treatment of severe or recurrent CDI, with high success rates reported in some studies 5, 6.

Treatment Outcomes and Comparisons

• A study comparing FMT with fidaxomicin and vancomycin found that FMT was superior to both fidaxomicin and vancomycin in achieving clinical and microbiological resolution of recurrent CDI 6.
• Another study found that fidaxomicin led to resolution of CDI in 60.6% of patients with inflammatory bowel disease, with FMT being an effective therapy for those who did not respond to fidaxomicin 7.
• The use of vancomycin and FMT has been shown to be effective in reducing recurrence rates and improving treatment outcomes for patients with CDI 3, 4, 5, 6.

Fecal Microbiota Transplantation (FMT)

• FMT is a recommended treatment for recurrent CDI, with high success rates reported in several studies 4, 5, 6.
• FMT can be used in combination with vancomycin for the treatment of severe or recurrent CDI, with the goal of restoring the gut microbiota and reducing recurrence rates 5, 6.
• The use of FMT has been shown to be effective in reducing the risk of recurrence and improving treatment outcomes for patients with CDI 4, 5, 6.