New Drugs and Devices From 2011 – 2012 That Might Change Your Practice

Joe Lex, MD

Disclosures

Western J Emerg Med. 2013;14(6):619-628. 

In This Article

Dificid® (Fidaxomicin)

Clostridium difficile is the most common cause of infectious diarrhea in hospitalized patients in North America and Europe, where both the incidence and severity of the disease have increased alarmingly since 2000. In most patients with this infection, there is a history of antibiotic or antineoplastic use within the prior 8 weeks. Its outcome can be anything from mild diarrhea to potentially-fatal pseudomembranous colitis. When identified, cessation of antibiotic is sufficient for cure in ~25% of victims.

Oral metronidazole and oral vancomycin (whose name is derived from the term "vanquish") have similar efficacy for mild to moderate C. difficile infection. Metronidazole is preferred due to concerns about cost and the potential for vancomycin resistance. For severe infections, response rates to oral vancomycin are significantly better than with oral metronidazole (response rates 97% versus 76% and 85% versus 65% for vancomycin and metronidazole, respectively in 2 studies).

Fidaxomicin shows similar efficacy to vancomycin and may be a therapeutic option in mild to moderate cases of C.difficile diarrhea, but a 10-day course costs approximately $2,800, significantly higher than a 10-day course of oral vancomycin (~$1300). If you reconstitute injectable vancomycin with sterile water and dilute it to a concentration of 50 mg/mL, then direct that it be used orally, possibly with flavoring syrup, the cost of a course of therapy is $60 or less.

The cheapest and apparently most effective treatment for infection with C. difficile appears to be fecal transplant, shown in several small series to completely correct the condition. This esthetically-disturbing treatment,described as early as 1958, is being used more and more frequently. It is also called fecal microbiota transplantation, or FMT. The procedure usually involves an infusion of bacterial fecal flora harvested from a healthy donor. The stool can be given by enema or colonoscopy, or through a nasogastric or nasoduodenal tube. Most patients recover clinically and have C. difficile eradicated after just 1 treatment. Donors should be tested for a wide array of bacterial and parasitic infections, including occult C. difficile.

Perhaps we should be encouraged to keep a healthy specimen of our own stool in refrigeration, as Autologous Restoration of Gastrointestinal Flora (ARGF) has also been recommended. Should you develop C. difficile, your stool flora are extracted with saline and filtered, then freeze-dried and placed in enteric-coated capsules, which you can take orally to restore your original colonic flora.

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