Either vancomycin (125 mg four times daily) or fidaxomicin (200 mg twice daily) for ten days is now the treatment recommendation for initial C. difficile infection in adults, explained Dr Stuart Johnson at the ECCMID 2019.1 These 2018 recommendations come from the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA).
The evidence for these treatment recommendations come from randomized controlled trials in patients with C. difficile infection, which showed sustained responses and initial cures following fidaxomicin or vancomycin treatments.
Metronidazole, which has been in use since the 1980s, is also recommended for mild-to-moderate cases if access to the other drugs is limited. Further, metronidazole or vancomycin is still an option for the treatment of non-severe C. difficile infection in children. For children with an initial episode of severe C. difficile, oral vancomycin is recommended over metronidazole.
Patients with early recurrent C. difficile can be managed with currently available antimicrobials, although the best regimen is not known and the current recommendations are weak and based on low or moderate quality evidence. One recommendation with moderate quality evidence includes a 10-day course of fidaxomicin rather than a standard 10-day course of vancomycin.
Faecal microbiota transplantation should be reserved for patients not responding to antibiotic management (e.g. after the 3rd recurrence of C. difficile).
Johnson noted that good clinical trials in recurrent CDI are still needed.
Question: Do your guidelines or practice differ based on the method used for detecting C. difficile infection?
Johnson: We didn’t make any recommendations based on the methods used, though, in the USA, PCR methods are more commonly used.