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Clostridium difficile Infections: Diagnosis, Treatment, and Prevention

Slide: 21 of 33

Comparative Effectiveness of Standard Antibiotic Treatment for CDI

There was moderate strength evidence that initial cure rates were similar for oral vancomycin versus metronidazole and vancomycin versus fidaxomicin. Similarly, none of the other head-to-head trials demonstrated superiority of any single antimicrobial for initial clinical cure, recurrence, or mean days to resolution of diarrhea. Antibiotic comparisons included: vancomycin versus metronidazole, vancomycin versus fidaxomicin, vancomycin versus nitazoxanide, bacitracin, and high-dose vancomycin; and metronidazole versus nitazoxanide. Metronidazole was also compared to metronidazole plus rifampin with no evidence of superiority but with a statistically significant higher mortality associated with the combination (5% versus 32%; P = 0.04). One RCT comparing vancomycin to metronidazole, using a prespecified subgroup analysis of 69 patients, found a small but significant increase in the proportion of subjects with severe CDI who achieved initial clinical cure with vancomycin, using a treatment-received analysis. This difference was not significant using a strict intention-to-treat analysis. There was also moderate strength evidence that recurrence rates were about 10 percent lower after treatment with fidaxomicin when compared with vancomycin (15 percent versus 25 percent; P = 0.005). Low strength evidence suggested that patients treated with vancomycin for a non-NAP1 (non-North American Pulsed Field type 1) strain infection were about 3 times as likely to have a recurrence than patients treated with fidaxomicin, but patients with the NAP1 strain had recurrence rates that did not differ significantly by treatment.