Guidelines suggest fidaxomicin over vancomycin for Clostridioides difficile infection

New guidance on treating Clostridioides difficile infection (CDI) was issued by the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America.

This 2021 focused update of the organizations' guidelines on CDI in adults specifically addresses the use of fidaxomicin and bezlotoxumab for the treatment of CDI. It was developed by a multidisciplinary expert panel based upon topic-specific systematic literature reviews, and it was published by Clinical Infectious Diseases on June 24.

The update includes three recommendations (two of which modify previous recommendations, the third a new one) and comments:

• For patients with an initial CDI episode, we suggest using fidaxomicin rather than a standard course of vancomycin (conditional recommendation, moderate certainty of evidence). Comment: This recommendation places a high value in the beneficial effects and safety of fidaxomicin, but its implementation depends upon available resources. Vancomycin remains an acceptable alternative.
• In patients with recurrent CDI episodes, we suggest fidaxomicin (standard or extended-pulsed regimen) rather than a standard course of vancomycin (conditional recommendation, low certainty evidence). Comment: Vancomycin in a tapered and pulsed regimen or vancomycin as a standard course are acceptable alternatives for a first CDI recurrence. For patients with multiple recurrences, vancomycin in a tapered and pulsed regimen, vancomycin followed by rifaximin, and fecal microbiota transplantation (FMT) are options in addition to fidaxomicin.
• For patients with a recurrent CDI episode within the last six months, we suggest using bezlotoxumab as a co-intervention along with standard-of-care antibiotics rather than standard-of-care antibiotics alone (conditional recommendation, very low certainty of evidence). Comment: This recommendation places a high value on potential clinical benefits, but implementation is often limited by feasibility considerations. In settings where logistics is not an issue, patients with a primary CDI episode and other risk factors for CDI recurrence (such as age >65 years, immunocompromise, and severe CDI on presentation) may particularly benefit from receiving bezlotoxumab. Data on the use of bezlotoxumab when fidaxomicin is used as the standard-of-care antibiotic are limited. The FDA warns that “in patients with a history of congestive heart failure, bezlotoxumab should be reserved for use when the benefit outweighs the risk.”

The update notes that the societies' recommendation on use of FMT was not changed but that multiple FDA alerts have recently described adverse events related to FMT. FMT is recommended only for patients with multiple recurrences of CDI in whom appropriate antibiotic treatments have failed and should be done only after appropriate screening of donor and donor fecal specimen.