Study Synopsis and Perspective

On October 29, ESCMID issued updated guidelines for CDI, reviewing treatment
options of antibiotics, toxin-binding resins and polymers, immunotherapy,
probiotics, and fecal or bacterial intestinal transplantation. The new
recommendations, published online October 5 in Clinical Microbiology and Infection,
advise antibiotic treatment for all but very mild cases of CDI.
CDI, which is potentially fatal, is now the leading cause of healthcare-acquired
infections in hospitals, having surpassed methicillin-resistant S aureus.
"[A]fter the recent development of new alternative drugs for the treatment of CDI
(e.g. fidaxomicin) in US and Europe, there has been an increasing need for an
update on the comparative effectiveness of the currently available antibiotic agents
in the treatment of CDI, thereby providing evidence-based recommendations on this
issue," write Sylvia B. Debast, MD, from the Centre for Infectious Diseases, Leiden
University Medical Center, Leiden, The Netherlands, and colleagues from the
ESCMID Committee.
The new guideline, which updates the 2009 ESCMID recommendations now used
widely in clinical practice, summarizes currently available CDI treatment options and
offers updated treatment recommendations on the basis of a literature search of
randomized and nonrandomized trials.
ESCMID and an international team of experts from 11 European countries developed
recommendations for different patient subgroups, including initial nonsevere
disease, severe CDI, first recurrence or risk for recurrent disease, multiple
recurrences, and treatment of CDI when patients cannot receive oral antibiotics.
Antibiotic Recommended in Most Cases
Specific recommendations include the following:

For nonepidemic, nonsevere CDI clearly induced by antibiotic use, with no

signs of severe colitis, it may be acceptable to stop the inducing antibiotic
and observe the clinical response for 48 hours. However, patients must be
monitored very closely and treated immediately for any signs of clinical
deterioration.

Antibiotic treatment is recommended for all cases of CDI except for very mild
CDI, which is actually triggered by antibiotic use. Suitable antibiotics include
metronidazole, vancomycin, and fidaxomicin, a newer antibiotic that can be
given by mouth.

For mild to moderate disease, metronidazole is recommended as oral

antibiotic treatment of initial CDI (500 mg 3 times daily for 10 days).

Fidaxomicin may be used in all patients with CDI for whom oral antibiotic
treatment is appropriate. Specific indications for fidaxomicin may include
first-line treatment in patients with first CDI recurrence or at risk for recurrent
disease, in patients with multiple recurrences of CDI, and in patients with
severe disease and nonsevere CDI.

These recommendations were based on two large phase 3 clinical studies that
compared 400 mg/day of oral fidaxomicin with 500 mg/day of oral vancomycin, the
standard of care. The rate of CDI recurrence was lower with fidaxomicin, but the
cure rate was similar for both treatments.

For severe CDI, suitable oral antibiotic regimens are vancomycin 125 mg 4
times daily (may be increased to 500 mg 4 times daily) for 10 days, or
fidaxomicin 200 mg twice daily for 10 days.

In life-threatening CDI, there is no evidence supporting the use of

fidaxomicin.

In severe CDI or life-threatening disease, the use of oral metronidazole is

strongly discouraged.

For multiple recurrent CDI, fecal transplantation is strongly recommended.

Total abdominal colectomy or diverting loop ileostomy combined with colonic

lavage is recommended for CDI with colonic perforation and/or systemic
inflammation and deteriorating clinical condition despite antibiotic treatment.

Additional measures for CDI management include discontinuing unnecessary

antimicrobial therapy, providing adequate fluid and electrolyte replacement,
avoiding antimotility medications, and reviewing proton pump inhibitor use.