From the Guidelines
No, Flagyl (metronidazole) should not be given together with Dificid (fidaxomicin) for C. difficile colitis, as Dificid is recommended as monotherapy for initial episodes or first recurrences of C. difficile infection. According to the 2021 clinical practice guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 1, the preferred treatment for an initial CDI episode is fidaxomicin 200 mg given twice daily for 10 days, with vancomycin 125 mg given 4 times daily by mouth for 10 days as an alternative. Metronidazole is only recommended as an alternative for nonsevere CDI if the above agents are unavailable.
The use of Dificid as monotherapy is supported by its mechanism of action, which inhibits RNA synthesis in C. difficile bacteria, and its minimal systemic absorption, allowing it to remain in the gut where the infection is located 1. Additionally, Dificid has been shown to have less impact on the normal gut microbiome compared to other antibiotics.
In terms of treatment selection, the guideline recommends considering the severity of infection, previous episodes, and patient-specific factors, such as age, immunocompromised status, and history of congestive heart failure 1. For example, bezlotoxumab may be considered as adjunctive treatment for patients with risks for CDI recurrence, but its use depends on available resources and logistics for intravenous administration.
Overall, the treatment of C. difficile colitis should be guided by the most recent and highest-quality evidence, and Dificid should be used as monotherapy for initial episodes or first recurrences of C. difficile infection, rather than in combination with Flagyl.
From the Research
Treatment of C. difficile Colitis
- The treatment of C. difficile colitis typically involves the use of antibiotics such as vancomycin, fidaxomicin, or metronidazole 2, 3, 4, 5, 6.
- Flagyl (metronidazole) is not typically recommended as a first-line treatment for C. difficile colitis, especially for severe cases or in patients with risk factors for recurrence 2, 6.
- Dificid (fidaxomicin) is a recommended treatment option for C. difficile colitis, particularly for initial episodes, first recurrences, and non-severe cases 4, 5.
- The combination of vancomycin and metronidazole may be used in some cases, but fidaxomicin has been shown to be superior in preventing recurrent C. difficile infection (rCDI) 3, 5.
Comparison of Treatment Options
- Fidaxomicin has been shown to have improved sustained cure rates and lower recurrence rates compared to vancomycin and metronidazole 4, 5.
- Vancomycin and fidaxomicin have been associated with higher odds of prolonged hospitalization, while fidaxomicin has been linked to increased odds of suffering another episode of C. difficile 3.
- The resistance profile of C. difficile to vancomycin and metronidazole has been reported, with vancomycin resistance decreasing and metronidazole resistance remaining stable over time 3.