Study Synopsis and PerspectiveOn 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 CasesSpecific 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.
