From the Guidelines
For a patient with C-diff, I strongly recommend fidaxomicin 200 mg given twice daily for 10 days as the preferred treatment for an initial episode, due to its superior efficacy and lower recurrence rates compared to vancomycin, as supported by the 2021 guidelines from the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 1.
Treatment Approach
The treatment approach for C-diff depends on the severity and clinical presentation of the disease.
- For an initial episode of C-diff, fidaxomicin 200 mg twice daily for 10 days is the preferred treatment, as it has been shown to have a higher clinical cure rate and lower recurrence rate compared to vancomycin 1.
- Vancomycin 125 mg four times daily for 10 days is an acceptable alternative, especially if fidaxomicin is not available 1.
- For severe C-diff, vancomycin 125 mg four times daily for 10 days is recommended, with consideration of a tapered and pulsed regimen for recurrent cases 1.
- In cases of fulminant C-diff, characterized by hypotension or shock, vancomycin 500 mg four times daily by mouth or nasogastric tube, plus intravenous metronidazole 500 mg every 8 hours, is the recommended treatment 1.
Recurrent Infections
For recurrent C-diff infections,
- fidaxomicin 200 mg twice daily for 10 days, or twice daily for 5 days followed by once every other day for 20 days, is a preferred treatment option, as it has been shown to be effective in reducing recurrence rates 1.
- Vancomycin in a tapered and pulsed regimen is an alternative option for recurrent cases 1.
- Fecal microbiota transplantation should be considered after multiple recurrences, as it has been shown to be effective in restoring the normal gut flora and preventing further recurrences 1.
Infection Control Measures
In addition to antimicrobial treatment,
- infection control measures such as contact precautions, hand hygiene with soap and water, and environmental cleaning with sporicidal agents are crucial in preventing the spread of C-diff 1.
- Discontinuation of unnecessary antibiotics and avoidance of anti-motility agents are also important in managing C-diff 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).
The recommended treatment for a patient with C-diff is fidaxomicin (DIFICID), as it is indicated for the treatment of C. difficile-associated diarrhea (CDAD) in adults and pediatric patients aged 6 months and older 2.
- Key points:
- Fidaxomicin should be used only to treat infections that are proven or strongly suspected to be caused by C. difficile.
- The medication should be taken exactly as directed, and patients should be advised to complete the full course of therapy to decrease the effectiveness of the immediate treatment and increase the likelihood that bacteria will develop resistance 2.
- Patients should be counseled that antibacterial drugs, including DIFICID, should only be used to treat bacterial infections, and they do not treat viral infections 2.
From the Research
Treatment Options for C-Diff
- For an initial episode of nonsevere C. difficile infection, oral vancomycin or oral fidaxomicin is recommended 3
- Fecal microbiota transplantation is a reasonable treatment option with high cure rates in patients who have had multiple recurrent episodes and have received appropriate antibiotic therapy for at least three of the episodes 3
- Standardized microbiome-based therapies, such as SER-109 and RBX2660, have demonstrated high efficacy rates and are now US Food and Drug Administration approved for recurrent C. difficile infection 4
Diagnosis and Testing
- Testing for C. difficile infection should start with enzyme immunoassays for glutamate dehydrogenase and toxins A and B or nucleic acid amplification testing 3
- Diagnosis is based on direct detection of C. difficile toxins in feces, most commonly with the use of EIA assay, but no single test is suitable as a stand-alone test confirming CDI 5
Prevention and Management
- Good antibiotic stewardship is a key strategy to decrease rates of C. difficile infection 3
- Hands should be cleaned with either soap and water or an alcohol-based product, but during outbreaks soap and water is superior 3
- The Infectious Diseases Society of America does not recommend the use of probiotics for prevention of C. difficile infection 3