Challenges in management of recurrent and refractory Clostridium difficile infection

Table 1 Management outline for recurrent Clostridium difficile infection[7]

General

Stop/minimize antibiotics (if possible, to allow gut flora to repopulate)

Rule out other causes of diarrhea, i.e., post-infectious IBS (check stool for C diff only in context of symptoms, not as test of cure)

Antibiotic treatment

Use the same antibiotic as initial regimen (depending on disease severity and response to initial treatment)[7,52]

Consider Vancomycin taper ± pulse[11]

Vancomycin followed by rifaximin chaser[67]

Fidaxomicin[80]

Probiotics

Probiotics with antibiotics may help[99]. Consider adding to last 2 wk of vancomycin pulse/taper and continue for 4 wk after (caution in immunocompromised patients- may cause fungemia. Don’t use in isolation. Not standardized, doses/active agents may vary)

Immunotherapy

Monoclonal antibody (neutralize toxin)[54]

IVIG[51]

Toxoid vaccine[58]

Non toxigenic strains[42]

Bacteriotherapy

Fecal microbiota transplant[111,114]

IBS: Irritable bowel syndrome; IVIG: Intravenous immunoglobulin.