It’s time to rethink your approach to C diff infection
Metronidazole is no longer the drug of choice for first-line therapy. And fecal microbiota transplantation has proven effective for certain patients.
PRACTICE RECOMMENDATIONS
› Keep in mind that previous exposure to antibiotics is the most important risk factor for initial and recurrent Clostridioides difficile infection (CDI). Thus, appropriate antimicrobial stewardship is key to prevention. C
› Begin with vancomycin or fidaxomicin (over metronidazole) for first-line treatment of CDI in adults. A
› Consider fecal microbiota transplantation in high-risk patients with recurrent CDI for whom antimicrobial therapy has failed. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE 2: Ms. Z has several risk factors for recurrent CDI and has an elevated WBC count and SCr level (WBC ≥ 15,000 and SCr > 1.5 mg/dL). Thus, she is classified as having severe, recurrent CDI. Oral levofloxacin and metronidazole should be discontinued, because they increase the risk for treatment failure and development of more virulent CDI strains, such as BI/NAP1/027. Since Ms. Z used metronidazole for treatment of her initial CDI, vancomycin or fidaxomicin should be used at this time. Either vancomycin PO 125 mg qid for 10 days or fidaxomicin 200 mg bid for 10 days would be an appropriate regimen; however, because of cost and unknown insurance coverage, vancomycin is the most appropriate regimen.
CORRESPONDENCE
Jeremy Vandiver, PharmD, BCPS, University of Wyoming School of Pharmacy, Saint Joseph Family Medicine Residency, 1000 E. University Avenue, Dept 3375, Laramie, WY 82071; jvandive@uwyo.edu
