Clostridioides difficile Infection: A Focused Guideline Update From the IDSA

ABSTRACT

Fidaxomicin is expensive, with a cost of about $4,300 for a 10-day course compared with $75 for a 10-day course of vancomycin. Because fidaxomicin has not been studied in fulminant infections, vancomycin with intravenous metronidazole (Flagyl) continues to be recommended in the rare cases of fulminant CDI. Bezlotoxumab Reduces Further Recurrence Bezlotoxumab (Zinplava) is a monoclonal antibody against C. difficile toxin B approved by the U.S. Food and Drug Administration (FDA) for prevention of recurrent CDI in high-risk adults. Recommended Treatment Options for CDI Presentation Treatment options Additional information Initial case Preferred  Fidaxomicin (Dificid), 200 mg twice daily for 10 days Alternative  Vancomycin, 125 mg four times daily for 10 days Alternative for nonsevere CDI if above agents not available  Metronidazole (Flagyl), 500 mg three times daily for 10 to 14 days Fidaxomicin Caution for use in patients with congestive heart failure Diagnosis of nonsevere cases supported by  White blood cell count < 15,000 cells per μL (15 × 109 per L)  Serum creatinine < 1.5 mg per dL (132.6 μmol per L) First recurrence Preferred  Fidaxomicin, 200 mg twice daily for 10 days or twice daily for five days followed by once every other day for 20 days Alternatives  Vancomycin in a tapered and pulsed regimen  Vancomycin, 125 mg four times daily for 10 days Adjunct  Bezlotoxumab (Zinplava), 10 mg per kg given intravenously once Tapered and pulsed vancomycin regimen example  125 mg four times daily for 10 to 14 days, two times daily for seven days, once daily for seven days, and then every two to three days for two to eight weeks Subsequent recurrences Preferred  Fidaxomicin, 200 mg twice daily for 10 days or twice daily for five days followed by once every other day for 20 days Alternatives  Vancomycin in a tapered and pulsed regimen  Vancomycin, 125 mg four times daily for 10 days, followed by rifaximin (Xifaxan), 400 mg three times daily for 20 days  Fecal microbiota transplantation Adjunct  Bezlotoxumab, 10 mg per kg given intravenously once Infectious Diseases Society of America guideline panel recommends appropriate antibiotic treatments should be tried for at least two recurrences (i.e., three CDI episodes) before offering fecal microbiota transplantation Fulminant CDI Vancomycin, 500 mg four times daily;if ileus is present, consider adding rectal dosing of vancomycin Metronidazole, 500 mg intravenously every eight hours, administered with oral or rectal vancomycin, particularly if ileus is present Definition of fulminant CDI is supported by  Hypotension or shock, ileus, megacolon CDI = Clostridioides difficile infection.