good day and happy new year. in the treatment section, is "Current first-line treatment is fidaxomicin, per 2018 IDSA guidelines, or oral vancomycin if fidaxomicin is not available" accurate? looking at the IDSA 2018 guidelines I found:
"XXIX. What are the best treatments of an initial CDI episode to ensure resolution of symptoms and sustained resolution 1 month after treatment? Recommendations 1. Either vancomycin or fidaxomicin is recommended over metronidazole for an initial episode of CDI. The dosage is vancomycin 125 mg orally 4 times per day or fidaxomicin 200 mg twice daily for 10 days (strong recommendation, high quality of evidence) (Table 1).
and...
"Based on these 2 large clinical trials and meta-analyses, fidaxomicin should be considered along with vancomycin as the drug of choice for an initial episode of CDI"
I could not find where fidax is first-line treatment if it is available in preference to vanco. I work in a community where it is available (although insanely expensive) but we haven't started using it and i'm wondering if i misinterpreted the ISDA rec's and we should be using it when the patient can afford to do so. i wonder if by de facto vanco will be the initial drug based on cost and availability tho
Hi Sean, Great question! The abridged IDSA recommendation from 2018 recommends either fidaxomicin or vancomycin. You are absolutely current that later down in their detailed discussion, the guidelines state “Based on these 2 large clinical trials and meta-analyses, fidaxomicin should be considered along with vancomycin as the drug of choice for an initial episode of CDI.”, but I believe they meant either option is a viable treatment, not both used together.
The guidelines were recently updated in 2021, recommending that for an initial episode or a recurrent episode, fidaxomicin should be used rather than oral vancomycin, though oral vanc remains an acceptable alternative. This is the big change from the prior guidelines that recommended either vancomycin or fidaxomicin over metronidazole for an initial episode of CDI.
Here is the link to the full text for the updated guidelines: https://www.idsociety.org/practice-guideline/clostridioides-difficile-2021-focused-update/#RecommendationsAbridged
I work in a similar situation where fidaxomicin remains expensive (about $250 per dose, about $500 per day since it’s 2 doses daily), though oral vancomycin is about $30 per dose (hopefully this is coming down but this comes out to $120 per day since it’s 4 doses daily). Fidaxomicin is the first line agent if possible. As you stated though, I do think oral vancomycin will be the more readily available medication due to cost. Metronidazole used to the main agent, but the evidence suggests it is not as effective as the other two agents. Much of this will come down to a discussion with the patient. If fidaxomicin is not available, oral vancomycin is the way to go. If they state they will not be able to complete treatment with oral vanc due to cost, it places us in a difficulty position. Oral metronidazole can be considered if the patient can’t use oral fidaxomicin or vanc due to cost, but the likelihood of cure is lower with oral metronidazole.
Thanks so much Brit! yes either or- god forbid someone uses fidax and vanc together! i'm still praying that the upcoming oral carbapenem isn't used for chronically colonized bladders!!!! HNY
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Sean R. - January 2, 2023 7:07 AM
good day and happy new year. in the treatment section, is "Current first-line treatment is fidaxomicin, per 2018 IDSA guidelines, or oral vancomycin if fidaxomicin is not available" accurate? looking at the IDSA 2018 guidelines I found:
"XXIX. What are the best treatments of an initial CDI episode to ensure resolution of symptoms and sustained resolution 1 month after treatment?
Recommendations
1. Either vancomycin or fidaxomicin is recommended over metronidazole for an initial episode of CDI. The dosage is vancomycin 125 mg orally 4 times per day or fidaxomicin 200 mg twice daily for 10 days (strong recommendation, high quality of evidence) (Table 1).
and...
"Based on these 2 large clinical trials and meta-analyses, fidaxomicin should be considered along with vancomycin as the drug of choice for an initial episode of CDI"
I could not find where fidax is first-line treatment if it is available in preference to vanco. I work in a community where it is available (although insanely expensive) but we haven't started using it and i'm wondering if i misinterpreted the ISDA rec's and we should be using it when the patient can afford to do so. i wonder if by de facto vanco will be the initial drug based on cost and availability tho
thx
Brit L. - January 2, 2023 10:00 AM
Hi Sean,
Great question! The abridged IDSA recommendation from 2018 recommends either fidaxomicin or vancomycin. You are absolutely current that later down in their detailed discussion, the guidelines state “Based on these 2 large clinical trials and meta-analyses, fidaxomicin should be considered along with vancomycin as the drug of choice for an initial episode of CDI.”, but I believe they meant either option is a viable treatment, not both used together.
The guidelines were recently updated in 2021, recommending that for an initial episode or a recurrent episode, fidaxomicin should be used rather than oral vancomycin, though oral vanc remains an acceptable alternative. This is the big change from the prior guidelines that recommended either vancomycin or fidaxomicin over metronidazole for an initial episode of CDI.
Here is the link to the full text for the updated guidelines: https://www.idsociety.org/practice-guideline/clostridioides-difficile-2021-focused-update/#RecommendationsAbridged
I work in a similar situation where fidaxomicin remains expensive (about $250 per dose, about $500 per day since it’s 2 doses daily), though oral vancomycin is about $30 per dose (hopefully this is coming down but this comes out to $120 per day since it’s 4 doses daily). Fidaxomicin is the first line agent if possible. As you stated though, I do think oral vancomycin will be the more readily available medication due to cost. Metronidazole used to the main agent, but the evidence suggests it is not as effective as the other two agents. Much of this will come down to a discussion with the patient. If fidaxomicin is not available, oral vancomycin is the way to go. If they state they will not be able to complete treatment with oral vanc due to cost, it places us in a difficulty position. Oral metronidazole can be considered if the patient can’t use oral fidaxomicin or vanc due to cost, but the likelihood of cure is lower with oral metronidazole.
Thanks!
Brit
Sean R. - January 4, 2023 9:12 AM
Thanks so much Brit! yes either or- god forbid someone uses fidax and vanc together! i'm still praying that the upcoming oral carbapenem isn't used for chronically colonized bladders!!!! HNY