From the Guidelines
For a 68-year-old female with suspected Clostridioides difficile infection following ampicillin use, the recommended treatment is Fidaxomicin 200 mg twice daily for 10 days, as it is the preferred treatment for initial CDI episodes, according to the 2021 focused update guidelines by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 1. This patient presents with classic risk factors for C. difficile, including recent antibiotic use, advanced age, and comorbidities like diabetes. Key considerations for treatment include:
- The patient's white blood cell count is 16,000, which is slightly above the definition of nonsevere CDI, but still within a range where Fidaxomicin or Vancomycin would be appropriate treatments 1.
- Fidaxomicin is now preferred over metronidazole for initial episodes of C. difficile infection due to superior cure rates and reduced recurrence, as stated in the guidelines 1.
- Vancomycin 125 mg four times daily by mouth for 10 days is an acceptable alternative treatment, but Fidaxomicin is preferred for its superior outcomes 1.
- Fecal microbiota transplantation is not indicated for first episodes of C. difficile infection but rather for multiple recurrences that have failed standard antibiotic therapy, as per the guidelines 1. The patient should be placed on contact precautions to prevent transmission, and her diabetes medications may need adjustment during the acute illness. Some key points to consider in the management of this patient include:
- Monitoring for signs of complications, such as hypotension, ileus, or megacolon, which would indicate fulminant CDI and require more aggressive treatment 1.
- Ensuring the patient has a clear understanding of the treatment plan and the importance of completing the full course of antibiotics.
- Considering the use of adjunctive treatments, such as Bezlotoxumab, in patients with high risk of recurrence, although this would not be the first-line treatment for this patient 1.
From the FDA Drug Label
2.2 Adult Patients The recommended dosage for adults is one 200 mg DIFICID tablet orally twice daily for 10 days.
The recommended course of treatment for Clostridioides difficile-associated diarrhea is Fidaxomicin 200 mg twice daily for 10 days 2.
From the Research
Treatment Options for Clostridioides difficile Infection
The patient's symptoms and history suggest a diagnosis of Clostridioides difficile infection. The recommended course of treatment depends on the severity of the infection and whether it is an initial or recurrent episode.
- For an initial episode of nonsevere C. difficile infection, oral vancomycin or oral fidaxomicin is recommended 3.
- Metronidazole is no longer recommended as first-line therapy for adults 3.
- Fidaxomicin has been shown to be effective in treating C. difficile infection, with a lower recurrence rate compared to vancomycin 4, 5.
- Fecal microbiota transplantation is a reasonable treatment option for patients with multiple recurrent episodes who have received appropriate antibiotic therapy 5, 3.
Specific Treatment Regimens
The following treatment regimens are recommended:
- Fidaxomicin 200 mg twice daily for 10 days 4, 5.
- Vancomycin 125 mg orally four times daily for 10 days 3.
- Metronidazole 500 mg three times daily for 10 days is not recommended as first-line therapy for adults 3.
- Fecal microbiota transplantation may be considered for patients with multiple recurrent episodes 5, 3.
Comparison of Treatment Outcomes
A systematic review and meta-analysis compared the effectiveness of fidaxomicin versus vancomycin or metronidazole in treating C. difficile infection 6. The results showed that fidaxomicin and vancomycin/metronidazole regimens did not have significant differences in terms of treatment outcomes, such as clinical cure, sustained cure, recurrence, and all-cause mortality. However, there was a significantly higher risk of treatment failure in patients taking fidaxomicin.