Additional Insight on Managing C. Difficile Infection

JUNE 19, 2018
MD Magazine Staff

Peter Salgo, MD: At this point, before we all leave, I think it’s important for us to go around the table. I’d like to give each of you, just a few moments, to provide our audience with some takeaways of what’s important to you. So, why don’t we start with Dr. Gerding?

Dale N. Gerding, MD: As you look at the new Clostridium difficile [C. diff] guidelines, there are 2 points that general practitioners should know. No. 1: The diagnosis is important. Wherever your laboratory is, and however you’re getting your laboratory information, you need to be able to interpret the tests of toxin versus PCR [polymerase chain reaction], which is detecting the organism itself. Toxin testing is the more specific test. We will perhaps see some backing off from strictly doing PCR testing. The other point for you to remember is that metronidazole is no longer a first-line recommended therapy for C. diff. You need to consider using vancomycin or fidaxomicin. I think that vancomycin will still remain to be the workhorse therapy for C. diff, but fidaxomicin also needs to be considered, especially if the patient is at high risk for recurrence.

Peter Salgo, MD: Dr Golan?

Yoav Golan, MD: Well, I would agree. I would say to only test patients with unexplained diarrhea. You don’t have to ask what’s causing the diarrhea if you already know the answer. When you diagnose C. diff in a patient, always ask yourself, “What’s the patient’s risk of recurrence?” Recurrence has been one of the main, if not main, unmet needs, I would argue, in C. diff. It’s very, very high. Use a strategy that will minimize recurrence in those patients who are at high risk.

Peter Salgo, MD: Dr Pardi, you’ve got the last word.

Darrell S. Pardi, MD: Maybe these are new data, but I think it’s important to get it out there. For treating recurrent C. diff, if we’re using vancomycin taper and pulse, we have some data that say that recurrence, even after a taper/pulse, is still about 40%. But it was a break, at 6 weeks, of total therapy. Those with tapers lasting longer than 6 weeks had about a 2-fold lower risk of recurrence than those who were treated for less weeks. So, the taper needs to have a significant amount of time to work.

The second thing relates to the use of fidaxomicin. We published data that demonstrated that it works better when you use it earlier in the infection. In our study, the recurrence rate was 0% when fidaxomicin was used after the first infection, 20% after the first recurrence, and 30% after the second recurrence. This is still lower than if we compared it to vancomycin, I’m sure, but the benefit is achieved earlier.

Peter Salgo, MD: I want to thank all 3 of you for being here. I learned a lot. My metronidazole use is going to zero. And right now, starting today, I’m going to go back and spread the gospel. This is important. This is an important infection. It’s an important cause of morbidity, and it’s a cause of mortality. It’s something that we’re all going to have to deal with, in the medical community, going forward. As our patients get older and sicker, more of them get antibiotics.

On behalf of our panel, I want to thank you for watching this, and I hope you’ll join us again. I’m Dr Peter Salgo, and I’ll see you next time.

Transcript edited for clarity.
 

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