C. Difficile Infection Treatments
C. DIFFICILE INFECTION TREATMENTS
The following are FDA-approved therapies for the management of Clostridioides difficile infection (CDI) in adults. Off-label therapies and dosing are based on recommendations from the Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) for the management of CDI.
Generic Brand Strength Form Adult Dose
FIRST CDI OCCURENCE1
Recommended
fidaxomicin Dificid 200mg tabs 200mg twice daily for 10 days.
40mg/mL granules for oral susp
Alternative
vancomycin2 Vancocin 125mg, 250mg caps 125mg 4 times daily for 10 days.
Firvanq 3.75g, 7.5g, 15g pwd for oral soln
metronidazole2,3 Flagyl 250mg, 500mg tabs Non-severe CDI: 500mg 3 times daily for 10−14 days.
RECURRENT CDI4
Recommended
fidaxomicin Dificid 200mg tabs First and subsequent recurrence: 200mg twice daily for 10 days4.
40mg/mL granules for oral susp
Alternative
vancomycin2 Vancocin 125mg, 250mg caps First recurrence: 125mg 4 times daily for 10 days5, or tapered/pulsed regimen4. Second or subsequent recurrence: tapered/pulsed regimen4, or 125mg 4 times daily for 10 days followed by rifaximin4.
Firvanq 3.75g, 7.5g, 15g pwd for oral soln
bezlotoxumab6 Zinplava 25mg/mL soln for IV infusion First and subsequent recurrence (adjunct): 10mg/kg once with standard of care antibiotics. Infuse over 60mins.
NOTES

Key: CDI = Clostridioides difficile infection

1 The IDSA/SHEA clinical practice guideline on the management of CDI recommends fidaxomicin over vancomycin as the preferred treatment for the first occurrence of CDI due to its safety and efficacy profile. Vancomycin is an accepted alternative, and metronidazole may be used if fidaxomicin and vancomycin are unavailable.

2 For the treatment of fulminant CDI, defined as the presence of hypotension, shock, ileus, or megacolon, consult the IDSA/SHEA clinical practice guideline on the management of CDI for its recommendation on vancomycin and metronidazole use.

3 The use of metronidazole for CDI is not an FDA-approved indication, however, the IDSA/SHEA guideline recommends off-label use as an alternative for non-severe CDI (eg, WBC ≤15,000 cells/µL and serum creatinine <1.5mg/dL) if fidaxomicin and vancomycin are unavailable.

4 For alternative dosing (eg, fidaxomicin extended regimen, tapered/pulsed vancomycin regimen) and off-label therapies (eg, rifaximin, fecal microbiota transplantation) for recurrent CDI, consult the IDSA/SHEA clinical practice guideline on the management of CDI.

5 Consider standard dosing (125mg 4 times daily) if metronidazole was used for first CDI episode.

6 Use only in conjunction with antibacterial drug treatment of CDI to reduce CDI recurrence in patients at high risk for recurrence (eg, age ≥65yrs, immunocompromised [per history or use of immunosuppressants], and severe CDI on presentation). Caution in patients with CHF.

 

Not an inclusive list of medications and/or official indications. Please see drug monograph at www.eMPR.com and/or contact company for full drug labeling.

REFERENCE

Johnson S, Lavergne V, Skinner AM, Gonzales-Luna AJ, Garey KW, Kelly CP, Wilcox MH. Clinical Practice Guideline by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults. Clinical Infectious Diseases. 2021;73(5):e1029–e1044. https://doi.org/10.1093/cid/ciab549.

Created 10/2022