Choosing Between Vancomycin and Fidaxomicin for C. Difficile Infections


Implications for prescribing vancomycin or fidaxomicin to treat C. difficile infections.

Peter L. Salgo, MD: Let me ask a simple yes/no question. I’m going to pick Paul. You’re on the hot spot. The data for recurrence with fidaxomicin [Dificid] versus vanco [vancomycin]; is fidaxomicin better? Is fidaxomicin better than vanco if you’re looking at recurrence, first infection?

Paul Feuerstadt, MD, FACG, AGAF: Fidaxomicin in terms of cost benefit?

Peter L. Salgo, MD: I don’t know, just the data for recurrence. I don’t care.

Paul Feuerstadt, MD, FACG, AGAF: Data for recurrence is relatively clear. There was a subgroup analysis from the original 2 phase 3 randomized controlled trials. It was published by Cornalee and colleagues, and within that there were 28% of the patients from the original pivotal trials that had an episode of C difficile within the prior 3 months. That group, the group that received vancomycin, went on to recur 35.5% of the time versus 19.7% in the fidaxomicin arm.

Peter L. Salgo, MD: OK. I rest my case, if I will.

Paul Feuerstadt, MD, FACG, AGAF: That’s a significant reduction in my eyes, but that data has been out for 9 years; there’s nothing new there. There are several what I consider very important studies that weren’t sided with the IDSA/SHEA [Infectious Diseases Society of America/Society for Healthcare Epidemiology of America] guideline update in 2020. The study that I like to talk about is a study by Goldenberg. It definitely did have some weaknesses, but it looked at the broad picture, which is an important thing to look at, where they compared a historical control group to the first year that fidaxomicin became available. They then looked at various health care systems that used fidaxomicin.

In 2 health care systems that decided to use fidaxomicin broadly, meaning every patient that had C difficile, 1 health care system’s recurrence rate went from 10.6% to 3.1%. The other, from 16.3% to 3.1%—remarkable decreases. But even in the health care system that used it for only for first recurrence, their recurrence rates went from 21.1% to 12.5%. What we’re seeing is no matter how fidaxomicin is being used, if a health care system commits to it, it seems to remarkably reduce those rates of recurrence, which really mimics what I call the ivory tower data, which is the phase 3 prospective, randomized, controlled trial data.

Peter L. Salgo, MD: If you enjoyed this content, you should subscribe. We have an e-newsletter, and you can receive upcoming Peer Exchanges and other great content in your inbox—that’s right, electronically. I’ll see you next time. I’m Dr Peter Salgo. Thanks again for watching.

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