Preventing Recurrence of C difficile Infection (CDI): The Need for Multiple Strategies

As Director of our Antibiotic Stewardship Committee at Detroit Medical Center, I am tasked with keeping pace with clinical practice guidelines to ensure we employ the latest evidence-based medicine to optimize treatment outcomes. New guidelines from the Infectious Diseases Society of America (IDSA) answer important questions about the treatment of initial and recurrent Clostridioides difficile infection (CDI).

New Guidelines Answer Key Questions
One important question is, “What is the preferred therapy for initial CDI?” IDSA guidelines recommend fidaxomicin over vancomycin for the initial episode of CDI, particularly in patients at high risk of recurrence.

But what constitutes high risk? To me, factors such as age older than 65 years, living in long-term care facilities, multiple comorbidities, and previous exposure to antibiotics, chemotherapy, or corticosteroids―all of which can cause dysbiosis―suggest your patient is at high risk of recurrence.

Eradication Is Not the Only Goal
As an expert in diagnosing and treating CDI, I prefer following the guidelines and using fidaxomicin as first-line therapy in high-risk patients with initial CDI because I want to decrease the chances of recurrence. For patients with ≥1 risk factor for recurrence, bezlotoxumab also may be beneficial if logistically possible.

But eradication is not my only goal―we also have to correct the underlying dysbiosis. Once the gut microbiome is disturbed, we must remove all the insults (eg, antibiotics, chemotherapy, diet) to return to its normal state. In some patients, a vicious cycle of dysbiosis can develop―and it never corrects. I believe this contributes to the multiple recurrences of CDI that I am increasingly seeing.

Reducing Recurrence
What about the patient with a history of multiple recurrences of CDI who remains at high risk for recurrence? It is important to assess underlying host factors―the risk factors mentioned earlier―and use your clinical acumen before ordering any diagnostic tests.

For example, imagine a patient who is older and has a history of diabetes, prior hospitalizations for urinary tract infections, 10 episodes of diarrhea in 24 hours, and abdominal pain, as well as a high white blood cell count. This is a patient to whom I definitely want to give fidaxomicin, but the underlying risk factors (immunosenescence) suggest that bezlotoxumab also would be beneficial in preventing future recurrence.

Important questions from healthcare professionals that I face as an infectious diseases consult include, “How can we prevent recurrence of C difficile, and how do I recognize modifiable risk factors for C difficile?” My answers typically start with questions: “How can we eliminate some of the modifiable risk factors? Is the patient taking proton pump inhibitors? Are there antibiotics we can stop?”

Then, we discuss guidelines: “Are you using microbiome-sparing agents such as fidaxomicin? Are you using immune-enhancing strategies such as bezlotoxumab?”

Moving Forward
In a nutshell, I believe the new IDSA guidelines offer an evidence-based approach for treating initial CDI and reducing multiple recurrences. That said, eradication is not our only goal―we must recognize modifiable risk factors for recurrence, treat the infection with appropriate microbiome-sparing and immune-enhancing interventions, and correct the underlying dysbiosis.

Although we may not completely eliminate recurrence, we certainly can decrease its incidence. The new guidelines are a wonderful and welcome guidance for treating CDI. I am excited about that, and you should be, too!

Your Thoughts?
How are you incorporating the latest CDI guidelines into your practice? Join the conversation by posting in the discussion section.