Managing Recurrent <i>C Difficile</i> Infection

Peter Salgo, MD: Let’s take a look at another group. We would like to give fidaxomicin to everybody. If the price were the same, maybe we would. But vancomycin still works, right? What about the folks who, no matter what they had as a first treatment, come back with recurrent C. diff [Clostridium difficile]? At this point, do you go to vancomycin, or does everybody get fidaxomicin? And if you’re going to use vancomycin, how do you use it?

Darrell S. Pardi, MD: The new guidelines really clarify that, in my mind. If a patient was treated with metronidazole in the first-line setting and has a recurrence, then you can use the standard dose of vancomycin for the first recurrence. If they received vancomycin for the first infection, then you could use either fidaxomicin or a tapered course of vancomycin for the first recurrence.

Peter Salgo, MD: And that’s it? How about multiple recurrences?

Yoav Golan, MD: When you treat the first episode of C. diff, you have to take the potential for recurrence into account. As I already mentioned, that may be the driver for using fidaxomicin. The goal is not to get into the situation of multiple recurrences. Once you are there, it’s really hard to do a lot with just medications. A lot of data suggest that. Can I make an off-label type of comment?

Peter Salgo, MD: You can, if it’s your personal opinion.

Yoav Golan, MD: When fidaxomicin was tested against vancomycin, it was tested twice a day for 10 days. I’ve been using fidaxomicin, as a tapered dose, from the get-go, for first episodes. As you mentioned earlier, the effect on the gut flora is relatively limited, and it actually allows you to restore your gut flora as you treat.

A recently published study, presented last year, highlighted the EXTEND study, where fidaxomicin was used as a taper and showed almost no recurrence at all. And so that’s how I use fidaxomicin. If you use it in the right way, you can reduce recurrence.

Dale N. Gerding, MD: In December, it published in the Lancet Infectious Diseases. It’s an interesting way to administer the drug. Normally, it would be given twice a day for 10 days. In this case, it was given twice a day for 5 days. Then the remaining 10 capsules were given every other day, out to day 25. So you extended it.

The measurement that you’re looking for in doing this is something called sustained cure. That’s the cure of the initial diarrhea episode and no recurrence afterward. Interestingly, the sustained cure was no different in that study than it was in the original phase 3 trials, when it was given twice a day. So it did not change the sustained cure. It did knock down the recurrence rate to about 5%. There was a really low recurrence rate. It suggests that maybe just 5 days or every other day is not as effective for cure because the sustained cure is a combination of cure and no recurrence. So I think we need to tinker around with this a little bit more, in terms of how we give the dose. The reason that this was not considered to be an increased economic burden is that you didn’t have to change the standard prescription. It was still 20 pills. You just staggered how you administered them.

Transcript edited for clarity.