What is the recommended treatment duration for a second episode of Clostridioides difficile (C. diff) infection?

From the Guidelines

For a second episode of Clostridioides difficile (C. diff) infection, treatment typically lasts 10-14 days with either oral vancomycin (125 mg four times daily) or fidaxomicin (200 mg twice daily), with vancomycin in a tapered and pulsed regimen or fidaxomicin being preferred options for recurrences due to lower recurrence rates, as supported by the 2021 focused update guidelines on management of Clostridioides difficile infection in adults 1.

Treatment Options

• Oral vancomycin (125 mg four times daily) for 10-14 days
• Fidaxomicin (200 mg twice daily) for 10-14 days
• Vancomycin in a tapered and pulsed regimen, which extends treatment to approximately 6-8 weeks total, as described in the guidelines 1
• Fidaxomicin in a tapered and pulsed regimen, as suggested by the 2021 update 1

Considerations

• Discontinue any unnecessary antibiotics to reduce the risk of recurrence
• Maintain good hydration to prevent dehydration
• Avoid anti-diarrheal medications, which can worsen the condition
• Consider fecal microbiota transplantation for multiple recurrences, as recommended by the guidelines 1

Evidence

The 2021 focused update guidelines on management of Clostridioides difficile infection in adults 1 provide the most recent and highest quality evidence for the treatment of recurrent C. diff infection. The guidelines recommend fidaxomicin as a preferred option for recurrences due to lower recurrence rates. The use of vancomycin in a tapered and pulsed regimen is also supported by the guidelines 1. Additionally, the guidelines suggest considering fecal microbiota transplantation for multiple recurrences, as supported by the evidence 1.

From the FDA Drug Label

In two trials, Vancomycin Hydrochloride Capsules 125 mg orally four times daily for 10 days was evaluated in 266 adult subjects with C. difficile-associated diarrhea (CDAD) The median time to resolution of diarrhea was 5 days and 4 days in Trial 1 and Trial 2, respectively. In subjects with diarrhea resolution at end-of-treatment with Vancomycin Hydrochloride Capsules, recurrence of CDAD during the following four weeks occurred in 25 of 107 (23%) and 18 of 102 (18%) in Trial 1 and Trial 2, respectively.

The treatment duration for a second episode of C-diff is 10 days with Vancomycin Hydrochloride Capsules 125 mg orally four times daily, as this is the duration that was evaluated in the clinical trials 2.

• The median time to resolution of diarrhea was 5 days and 4 days in Trial 1 and Trial 2, respectively.
• Recurrence rates were 23% and 18% in Trial 1 and Trial 2, respectively, during the four weeks following treatment.

From the Research

Treatment Duration for Second Episode of C-Diff

• The treatment duration for a second episode of C-Diff is not explicitly stated in the provided studies, but the standard treatment duration for C-Diff infection is typically 10 days 3, 4.
• Fidaxomicin and vancomycin are commonly used treatments for C-Diff infection, with fidaxomicin being associated with a lower rate of recurrence 3, 5.
• For patients with recurrent C-Diff infection, fecal microbiota transplantation (FMT) has been shown to be an effective treatment option, with a higher success rate compared to fidaxomicin and vancomycin 4.

Treatment Options for Second Episode of C-Diff

• Fidaxomicin is suggested as a treatment option for initial and recurrent C-Diff infection 5.
• Vancomycin is an acceptable alternative treatment option, followed by rifaximin and FMT 5.
• Bezlotoxumab is suggested for recurrent cases within 6 months 5.
• FMT has been shown to be superior to fidaxomicin for treatment of recurrent C-Diff infection, with a higher rate of clinical and microbiological resolution 4.

Considerations for Treatment of Second Episode of C-Diff

• Patients who fail to improve within 3 to 5 days of therapy may require surgical consultation for total colectomy 5.
• Patients with inflammatory bowel disease and C-Diff infection may require special consideration, with fidaxomicin being an effective treatment option in some cases 6.
• The choice of treatment for a second episode of C-Diff should be based on the individual patient's circumstances and medical history, and may involve consultation with a healthcare professional 3, 5, 4, 7, 6.