Controversies in the Prevention and Treatment of Clostridioides difficile Infection in Adults: A Narrative Review

Abstract

Clostridioides difficile remains a problematic pathogen resulting in significant morbidity and mortality, especially for high-risk groups that include immunocompromised patients. Both the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (IDSA/SHEA), as well as the American College of Gastroenterology (ACG) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) recently provided guideline updates for C. difficile infection (CDI). In this narrative review, the authors reviewed available literature regarding the prevention or treatment of CDI in adults and focused on disagreements between the IDSA/SHEA and ACG guidelines, as well as articles that have been published since the updates. Several options for primary prophylaxis are available, including probiotics and antibiotics (vancomycin, fidaxomicin). The literature supporting fidaxomicin is currently quite limited. While there are more studies evaluating probiotics and vancomycin, the optimal patient populations and regimens for their use have yet to be defined. While the IDSA/SHEA guidelines discourage metronidazole use for mild CDI episodes, evidence exists that it may remain a reasonable option for these patients. Fidaxomicin has an advantage over vancomycin in reducing recurrences, but its use is limited by cost. Despite this, recent studies suggest fidaxomicin’s cost-effectiveness as a first-line therapy, though this is highly dependent on institutional contracts and payment structures. Secondary prophylaxis should focus on non-antimicrobial options to lessen the impact on the microbiome. The oral option of fecal microbiota transplantation (FMT), SER109, and the now FDA-approved RBX2660 represent exciting new options to correct dysbiosis. Bezlotoxumab is another attractive option to prevent recurrences. Further head-to-head studies of newer agents will be needed to guide selection of the optimal therapies for CDI primary and secondary prophylaxis.

Microbiota-Based Live Biotherapeutic Products for Clostridioides Difficile Infection- The Devil is in the Details

“… 137 Similar analyses advocating for bezlotoxumab have been performed and yet pharmacy budgets have not been increased to account for inpatient use and payors continue to impede prescribing it without prior authorization. 138 , 139 Whether an increased number of therapeutic options for rCDI will influence the costs of existing agents on the market remains to be seen. Ultimately, the choice of LBP selected for rCDI prevention will depend on patient preference, prescriber opinion, and cost.…”

Automatic, web-based typing ofClostridioides difficileribotypes using MALDI-TOF MS

“…These methods are considered the gold standard to differentiate C. difficile RTs. They are highly informative, but also time-consuming (48-96h respectively from bacterial culture) and labor-intensive, requesting highly trained personnel and specific instruments, both factors lacking in most diagnostic laboratories (Bidet, Lalande, et al 2000; Abad-Fau, Sevilla et al 2023). The Xpert ® C. difficile BT assay has been implemented worldwide for the rapid differentiation of toxigenic C. difficile strains (Bai, Hao et al 2021).…”

Unveiling the threat: Characterization ofClostridioides difficileInfection in the Northwest Region of Buenos Aires between 2019-2023 and Associated Risk Factors redefined through a Meta-Analysis

“…Common therapy for CDI includes antibiotics such as metronidazole for mild cases and vancomycin or fidaxomicin for moderate to severe cases 6 . Therapies with the human antibody bezlotoxumab against C. difficile toxin B or Fecal Microbiota Transplant (FMT) to restore the balance of the microbiome have been recommended to treat or prevent recurrences 7,8 .…”