From the Guidelines
The most effective treatment for Clostridioides difficile (C. diff) infection is fidaxomicin 200 mg given twice daily for 10 days, as recommended by the 2021 focused update guidelines by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 1. When considering treatment options, it's essential to assess the severity of the infection and the patient's medical history.
- For an initial CDI episode, fidaxomicin is the preferred treatment, with vancomycin 125 mg given four times daily by mouth for 10 days as an acceptable alternative 1.
- For first CDI recurrence, fidaxomicin or a tapered and pulsed vancomycin regimen is recommended, with adjunctive treatment using bezlotoxumab 10 mg/kg given intravenously once during administration of standard of care antibiotics, although caution is advised in patients with congestive heart failure 1.
- For second or subsequent CDI recurrences, treatment options include fidaxomicin, vancomycin in a tapered and pulsed regimen, or vancomycin followed by rifaximin, with fecal microbiota transplantation considered after multiple recurrences 1.
- In cases of fulminant CDI, vancomycin 500 mg four times daily by mouth or by nasogastric tube, with or without rectal instillation, and intravenous metronidazole 500 mg every 8 hours, is the recommended treatment 1. It's crucial to prioritize treatment strategies that minimize morbidity, mortality, and impact on quality of life, while also considering the potential risks and benefits of each treatment option, as outlined in the 2021 guidelines 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).
- Treatment of C. difficile-associated diarrhea (CDAD): Fidaxomicin (DIFICID) is indicated for the treatment of CDAD in adult and pediatric patients aged 6 months and older.
- Dosage: The recommended dosage for adults is one 200 mg DIFICID tablet orally twice daily for 10 days 2.
- Key consideration: DIFICID should be used only to treat infections that are proven or strongly suspected to be caused by C. difficile 2.
From the Research
Treatment Options for C. Diff
- The treatment of Clostridium difficile infection (CDI) has evolved over the years, with various therapeutic approaches being developed and tested 3.
- According to the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guidance document, oral vancomycin is proposed as the first-line therapy for CDI, with fidaxomicin being a good alternative, especially in patients at risk of relapse 3.
- Fecal microbiota transplantation (FMT) has shown promising results in the treatment of recurrent CDI, with studies demonstrating its superiority over fidaxomicin and vancomycin 4, 5.
Fecal Microbiota Transplantation (FMT)
- FMT has been found to be an effective treatment for recurrent CDI, with a network meta-analysis showing that donor FMT is the most efficacious treatment compared to vancomycin and fidaxomicin 5.
- A randomized trial found that FMT combined with vancomycin (FMTv) was superior to fidaxomicin and vancomycin in achieving clinical and microbiological resolution in patients with recurrent CDI 4.
Emerging Treatments
- Novel therapies, including ridinilazole, SER-109, RBX2660, and a vaccine, are in various stages of development for the treatment of CDI 6, 7.
- These emerging treatments aim to address the growing concern of antibiotic resistance and the need for more effective prevention and treatment strategies for CDI 6, 7.
Current Guidelines and Recommendations
- The 2017 Infectious Diseases Society of America (IDSA) guidelines recommend the use of oral vancomycin or fidaxomicin as first-line treatment for initial CDI episodes, and FMT for patients with three or more recurrent CDI episodes 7.
- The guidelines also emphasize the importance of considering the cost-effectiveness of treatments for CDI, given the higher cost of newer agents 7.