Antibiotic Treatment for Clostridium Difficile-Associated Diarrhea (Cdi) in Adults

A Cochrane review [Abstract] 1 included 22 studies with a total of 3215 subjects.

The majority of studies enrolled patients with mild to moderate CDI who could tolerate oral antibiotics. Sixteen of the included studies excluded patients with severe CDI and few patients with severe CDI were included in the other six studies. Twelve different antibiotics were investigated: vancomycin, metronidazole, fusidic acid, nitazoxanide, teicoplanin, rifampin, rifaximin, bacitracin, cadazolid, LFF517, surotomycin and fidaxomicin. Most of the studies were active comparator studies comparing vancomycin with other antibiotics. One small study compared vancomycin to placebo. There were no other studies that compared antibiotic treatment to a placebo or a 'no treatment' control group.

Vancomycin was found to be more effective than metronidazole for achieving symptomatic cure. 72% (318/444) of metronidazole patients achieved symptomatic cure compared to 79% (339/428) of vancomycin patients (RR 0.90, 95% CI 0.84 to 0.97). Fidaxomicin was found to be more effective than vancomycin for achieving symptomatic cure. 71% (407/572) of fidaxomicin patients achieved symptomatic cure compared to 61% (361/592) of vancomycin patients (RR 1.17, 95% CI 1.04 to 1.31). Teicoplanin may be more effective than vancomycin for achieving a symptomatic cure. 87% (48/55) of teicoplanin patients achieved symptomatic cure compared to 73% (40/55) of vancomycin patients (RR 1.21, 95% CI 1.00 to 1.46).

One hundred and forty deaths were reported in the studies, all of which were attributed by study authors to the co-morbidities of the participants that lead to acquiring CDI. Although many other adverse events were reported during therapy, these were attributed to the participants' co-morbidities. The only adverse events directly attributed to study medication were rare nausea and transient elevation of liver enzymes.

Comment: The quality of evidence is downgraded by study quality (inadequate or unclear allocation concealment and blinding) and by imprecise results (few patients and wide confidence intervals).

The following decision support rules contain links to this evidence summary:

• Metronidazole in preference to vancomycin as the first choice in Clostridium difficile diarrhoea http://www.ebmeds.org/ebmeds/ebmeds_home.asp?mode=scripts&submode=view&id=scr00528&country=UK

References

• Nelson RL, Suda KJ, Evans CT. Antibiotic treatment for Clostridium difficile-associated diarrhoea in adults. Cochrane Database Syst Rev 2017;(3):CD004610. [PubMed].