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Oral Vancomycin versus Fidaxomicin for Treatment of Initial Clostridioides Difficile Infection
Thursday April 24, 2025 4:40pm - 4:55pm EDT
Parthenon 2
TITLE:    Oral Vancomycin vs Fidaxomicin for Treatment of Initial Clostridioides Difficile Infection   
Olivia Hill, Marcus Mize, Serina Tart
BACKGROUND: The 2021 Society for Healthcare Epidemiology of America/Infectious Diseases Society of America (SHEA/IDSA) Update to the Clinical Practice Guidelines for the Management of Clostridioides difficile infection (CDI) in Adults recommends oral (PO) fidaxomicin 200 milligrams (mg) twice daily for 10 days as the preferred therapy for an initial severe or non-severe CDI episode due to lower rates of recurrence.  Cost is a substantial barrier to fidaxomicin use and often leads to the utilization of PO vancomycin as the alternative initial treatment agent in practice. This research project aimed to evaluate the differences in treatment failure, rate of recurrence, and treatment cost between vancomycin and fidaxomicin for the treatment of initial CDI to provide additional information to help guide the choice between the two agents. 
METHODS: This multicenter, retrospective, observational cohort study examined patients with confirmed first occurrence of mild to severe CDI who were admitted to hospitals within the Cape Fear Valley Health System (CFVHS) from January 1, 2023, to December 31, 2023. Included patients were 18 years or older and had a confirmed CDI defined as positive antigen/toxin or PCR test. Patients were excluded if they had a fulminant or recurrent CDI, were actively being treated for other infections, or had received bezlotoxumab. The primary outcome assessed the differences in composite endpoint of treatment failure and/or 30-day recurrence rates in patients with documented first occurrence of CDI treated with vancomycin versus fidaxomicin. Secondary outcomes included differences in the rate of treatment failure and rate of 30-day recurrence between groups as well as differences in mean treatment cost between intensive care unit (ICU) setting versus medical/surgical floors.
RESULTS: Sixty-seven patients met inclusion criteria with 7 patients in the fidaxomicin group and 60 in the PO vancomycin group. The most common reason for exclusion was treatment for concurrent infections. Of patients included, 47.8% had community acquired CDI, 94.0% of patients had non-severe CDI, and 97.0% were admitted to a medical/surgical floor at the time of diagnosis. The average length of stay from time of diagnosis was 6.48 days. For the primary outcome, 7 (11.7%) patients in the vancomycin group experienced treatment failure or 30-day recurrence compared to 3 (42.9%) patients in the fidaxomicin group (p=0.0284). Treatment failure was experienced by 5 (8.3%) patients in the PO vancomycin group compared to 3 (42.9%) patients in the fidaxomicin group (p=0.0077). Recurrence at 30 days was experienced by 2 (3.3%) patients in the PO vancomycin group compared to 1 (14.3%) patient in the fidaxomicin group (p=0.1849). All fidaxomicin patients were located on a medical/surgical floor. The mean treatment cost for those in the PO vancomycin group was $8,752.05 (± $10,067.92) versus $7,148.09 (± $3239.33) in the fidaxomicin group, with a cost difference of $1603.96 (95% CI –2081.1 to 5289.0, p=0.7506). 
CONCLUSION: A limitation of this study was the lack of an adequate sample size in the fidaxomicin group which led to wide intergroup variability, making it difficult to draw conclusions. Within the PO vancomycin group, there were lower rates of treatment failure, 30-day recurrence, and 1-year recurrence compared to fidaxomicin. Although the results of this study are hypothesis-generating, it supports the idea that PO vancomycin could be utilized as a first-line option for initial CDI without increasing the risk of recurrence or treatment failure. More studies should be conducted to further analyze the potential for vancomycin’s place as a first-line agent for initial CDI.
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Presenters
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Olivia Hill

PGY1 Acute Care Pharmacy Resident, Cape Fear Valley Medical Center
My name is Olivia Hill and I am currently a PGY1 Acute Care Pharmacy Resident at Cape Fear Valley Medical Center in Fayetteville, NC. I graduated from Campbell University College of Pharmacy & Health Sciences in 2024. After completing my PGY1, I will be headed to University Health... Read More →
Thursday April 24, 2025 4:40pm - 4:55pm EDT
Parthenon 2
  Internal Medicine (IM), Cape Fear Valley Medical Center
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