From the Guidelines
Comprehensive management of Clostridioides difficile (C. diff) infection requires a multifaceted approach focusing on appropriate antimicrobial therapy, infection control measures, and supportive care, with the most recent guidelines from 2021 recommending fidaxomicin 200 mg twice daily for 10 days as the preferred treatment for initial non-severe C. diff infection, and vancomycin 125 mg four times daily for 10 days as an acceptable alternative 1. For initial non-severe C. diff infection,
- oral vancomycin 125 mg four times daily for 10 days
- or fidaxomicin 200 mg twice daily for 10 days is recommended. For severe infection,
- oral vancomycin 125 mg four times daily for 10 days is the preferred treatment. In fulminant cases with hypotension or shock,
- higher doses of oral vancomycin (500 mg four times daily) plus intravenous metronidazole 500 mg every 8 hours should be used,
- with consideration for surgical consultation if clinical deterioration occurs. For recurrent infections,
- extended vancomycin tapered regimens (125 mg four times daily for 10-14 days, then twice daily for 7 days, then once daily for 7 days, then every 2-3 days for 2-8 weeks)
- or fidaxomicin (200 mg twice daily for 10 days) are effective. Fecal microbiota transplantation should be considered after multiple recurrences,
- with the opinion of the panel being that appropriate antibiotic treatments for at least 2 recurrences (ie, 3 CDI episodes) should be tried prior to offering fecal microbiota transplantation 1. Infection control measures include
- contact precautions,
- hand hygiene with soap and water (alcohol-based sanitizers are less effective against C. diff spores),
- environmental cleaning with sporicidal agents,
- and antibiotic stewardship to reduce unnecessary antibiotic use. Probiotics may be considered for prevention in high-risk patients receiving antibiotics,
- with the effectiveness of these treatments stemming from their ability to eliminate the pathogen while allowing restoration of normal gut microbiota,
- which provides colonization resistance against C. diff 1. Additionally, adjunctive treatment with bezlotoxumab 10 mg/kg given intravenously once during administration of standard of care antibiotics may be considered for patients with recurrent CDI,
- particularly those with risk factors for recurrence such as age >65 years, immunocompromised host, and severe CDI on presentation 1. It is essential to note that the management of C. diff infection should be individualized based on the severity of the disease,
- the presence of risk factors for recurrence,
- and the patient's underlying medical conditions,
- with the goal of reducing morbidity, mortality, and improving quality of life 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).
2 DOSAGE AND ADMINISTRATION 2.1 Important Administration Instructions DIFICID is available for oral administration as 200 mg tablets and as granules for oral suspension (40 mg/mL (200 mg/5 mL) when reconstituted).
2.2 Adult Patients The recommended dosage for adults is one 200 mg DIFICID tablet orally twice daily for 10 days.
2.3 Pediatric Patients (6 Months to Less than 18 Years of Age) Tablets The recommended dosage for pediatric patients weighing at least 12.5 kg and able to swallow tablets is one 200 mg DIFICID tablet administered orally twice daily for 10 days.
Comprehensive Management of C. difficile Infection:
- Treatment: Fidaxomicin (DIFICID) is indicated for the treatment of C. difficile-associated diarrhea (CDAD) in adult and pediatric patients aged 6 months and older.
- Dosage: The recommended dosage for adults is 200 mg orally twice daily for 10 days. For pediatric patients, the dosage is based on weight, with tablets or oral suspension administered twice daily for 10 days.
- Administration: DIFICID can be taken with or without food. For pediatric patients, the oral suspension should be prepared by a healthcare professional and administered using an oral dosing syringe.
- Patient Counseling: Patients should be counseled to take DIFICID exactly as directed, complete the full course of therapy, and not skip doses to reduce the development of drug-resistant bacteria 2.
From the Research
Comprehensive Management of C. difficile Infection
- The management of C. difficile infection (CDI) involves a range of strategies, including diagnosis, treatment, and prevention of recurrence 3.
- Diagnosis of CDI should be considered in patients with three or more episodes of unexplained, unformed stools in 24 hours, and testing should start with enzyme immunoassays for glutamate dehydrogenase and toxins A and B or nucleic acid amplification testing 3.
- Treatment of CDI depends on the severity of the infection and whether it is an initial or recurrent episode, with oral vancomycin or fidaxomicin recommended for initial episodes of non-severe CDI 3, 4, 5, 6.
Treatment Options
- Vancomycin is a commonly used treatment for CDI, with a recommended dose of 125 mg four times daily for severe CDI 7.
- Fidaxomicin is also effective in treating CDI, with some studies suggesting it may be superior to vancomycin in terms of recurrence rate and long-term mortality 5, 6.
- Metronidazole is no longer recommended as first-line therapy for adults with CDI 3.
- Fecal microbiota transplantation is a reasonable treatment option for patients with multiple recurrent episodes of CDI who have received appropriate antibiotic therapy 3.
Prevention of Recurrence
- Good antibiotic stewardship is a key strategy to decrease rates of CDI 3.
- Hand hygiene with soap and water or an alcohol-based product is important in preventing the spread of CDI, with soap and water superior in outbreak settings 3.
- Probiotics are not recommended for the prevention of CDI 3.
- The use of fidaxomicin may be associated with a lower risk of recurrence compared to vancomycin 5, 6.