Dr Jessica Allegretti on Prevention and Treatment Strategies for Primary, Recurrent CDI


Jessica Allegretti, MD, MPH, medical director of the Crohn's and Colitis Center, Brigham and Women's Hospital, discusses the standard of care for the prevention and treatment of primary and recurrent Clostridioides difficile infection (CDI).

An estimated 20% to 25% of patients with primary Clostridioides difficile infection (CDI) experience recurrence of disease, with current strategies for the prevention and treatment of CDI including antibiotic stewardship, fecal microbiota transplantation, or use of emerging live biotherapeutics, said Jessica Allegretti, MD, MPH, medical director of the Crohn's and Colitis Center, Brigham and Women's Hospital.


What is the current standard of care for the prevention and treatment of initial CDI? Do management efforts change in any way for recurrent CDI?

There is an algorithm now that helps us think through management. So, for primary C diff, unfortunately, we don't have any good preventive strategies yet, other than antibiotic stewardship, as I mentioned, and good hand washing. Those are really the best things you can do.

With regards to treatment for primary C diff, if you're looking at the ACG, or American College of Gastroenterology, guidelines, there are 2 options for primary C diff, whether it's nonsevere or severe. And that's a vancomycin [vanco], as well as fidaxomicin. The IDSA, or the Infectious Disease Society, had similar guidelines, although this past year, they did issue an addendum to their guidance stating that they preferred fidaxomicin over vancomycin for first line, for either severe or nonsevere primary C diff.

Management certainly does change once the patient enters the arena of recurrent disease. It's important to remember that about 20% to 25% of patients will end up recurring. Why that happens, I think there's still a lot of work being done. But once the patient experiences a first recurrence, their likelihood of having a second, third, or further becomes exponentially more likely.

Once you're down this path of recurrence, the treatment strategies also become different. So, you certainly want to try an extended course of vanco or vanco taper if you haven't yet; certainly use fidaxomicin if you haven't yet. Rreally, I think the biggest change once you get into the recurrent disease arena is, you also need to have a preventive strategy.

So, treatment still is with an antibiotic as of now. We don't have any other treatments available, but we do have a lot of preventive strategies, and that can range from prophylactic, long-term vancomycin use; bezlotoxumab, which is an intravenous infusion of a monoclonal antibody against toxin B; fecal microbiota transplantation; or some of the emerging LBPs [live biotherapeutic products] that are either newly FDA approved or seeking FDA approval.

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