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European Practice for CDI Treatment

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Updates on Clostridioides difficile in Europe

Part of the book series: Advances in Experimental Medicine and Biology ((AMIDPH,volume 1435))

Abstract

Clostridioides difficile infection (CDI) remains a significant cause of morbidity and mortality worldwide. Historically, two antibiotics (metronidazole and vancomycin) and a recent third (fidaxomicin) have been used for CDI treatment; convincing data are now available showing that metronidazole is the least efficacious agent. The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) management guidance for CDI were updated in 2021. This guidance document outlines the treatment options for a variety of CDI clinical scenarios and for non-antimicrobial management (e.g., faecal microbiota transplantation, FMT). One of the main changes is that metronidazole is no longer recommended as first-line CDI treatment. Rather, fidaxomicin is preferred on the basis of reduced recurrence rates with vancomycin as an acceptable alternative. Recommended options for recurrent CDI now include bezlotoxumab as well as FMT.

A 2017 survey of 20 European countries highlighted variation internationally in CDI management strategies. A variety of restrictions were in place in 65% countries prior to use of new anti-CDI treatments, including committee/infection specialist approval or economic review/restrictions. This survey was repeated in November 2022 to assess the current landscape of CDI management practices in Europe. Of 64 respondents from 17 countries, national CDI guidelines existed in 14 countries, and 11 have already/plan to incorporate the ESCMID 2021 CDI guidance, though implementation has not been surveyed in 6. Vancomycin is the most commonly used first-line agent for the treatment of CDI (n = 42, 66%), followed by fidaxomicin (n = 30, 47%). Six (9%) respondents use metronidazole as first-line agent for CDI treatment, whereas 22 (34%) only in selected low-risk patient groups. Fidaxomicin is more likely to be used in high-risk patient groups. Availability of anti-CDI therapy influenced prescribing in six respondents (9%). Approval pre-prescription was required before vancomycin (n = 3, 5%), fidaxomicin (n = 10, 6%), bezlotoxumab (n = 11, 17%) and FMT (n = 10, 6%). Implementation of CDI guidelines is rarely audited.

Novel anti-CDI agents are being evaluated; it is not yet clear what will be the roles of these agents. The treatment of recurrent CDI is particularly troublesome, and several different live biotherapeutics are being developed, in addition to FMT.

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Acknowledgements

We wish to thank colleagues who took the time to complete the online survey of CDI treatment in Europe in November 2022.

Conflicts of Interest

FF has received research grant support and been a recipient of a consultancy fee from Tillots Pharma.

JvP has received research grant support by Merck Sharp & Dohme.

MW has received consulting fees from the following: AiCuris, Bayer, Crestone, Da Volterra, Deinove, EnteroBiotix, the European Tissue Symposium, Ferring, GSK, Menarini, Merck, Nestlé, Paion, Paratek, Pfizer, Phico Therapeutics, Qpex Biopharma, Seres, Surface Skins, Summit, Tillotts, Vaxxilon/Idorsia and Vedanta; Lecture fees from GSK, Merck, Pfizer, Seres & Tillotts; and Grant support from Almirall, Da Volterra, EnteroBiotix, GSK, Merck, MicroPharm, Nabriva, Paratek, Pfizer, Seres, Summit, the European Tissue Symposium and Tillotts.

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Authors and Affiliations

  1. Department of Clinical Microbiology, The Royal College of Surgeons in Ireland, Dublin, Ireland

    Fidelma Fitzpatrick, Robert Brennan & Mairead Skally

  2. Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland

    Fidelma Fitzpatrick, Mairead Skally & Karen Burns

  3. Department of Medical Microbiology, Leiden University Medical Center, Leiden, the Netherlands

    Joffrey van Prehn

  4. Health Protection Surveillance Centre (HPSC), Dublin, Ireland

    Melissa Brady

  5. Microbiology, Leeds Teaching Hospitals, Leeds, UK

    Christopher Rooney

  6. University of Leeds, Leeds, UK

    Christopher Rooney & Mark H. Wilcox

  7. Leeds Teaching Hospitals and Leeds Regional Public Health Laboratory, UK Health Security Agency (UKHSA), Leeds, UK

    Mark H. Wilcox

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Correspondence to Fidelma Fitzpatrick or Mark H. Wilcox .

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  1. Former Research Director in the Department of Infectious Diseases, National Institute of Health (ISS), Rome, Italy

    Paola Mastrantonio

  2. Department for Microbiological Research, National Laboratory of Health, Environment and Food (NLZOH), Maribor, Slovenia

    Maja Rupnik

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Fitzpatrick, F. et al. (2024). European Practice for CDI Treatment. In: Mastrantonio, P., Rupnik, M. (eds) Updates on Clostridioides difficile in Europe. Advances in Experimental Medicine and Biology(), vol 1435. Springer, Cham. https://doi.org/10.1007/978-3-031-42108-2_4

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