Clinical trial data support the use of vancomycin over metronidazole for those with initial Clostridium difficile infection (CDI), and fidaxomicin over vancomycin for the prevention of recurrent infection, according to a newly-released update of the 2011 Agency for Healthcare Research and Quality Comparative Effectiveness Review.
In contrast, data were considered to be weak though consistent in their pattern of efficacy regarding the use of fecal microbiota transplantation and lactobacillus probiotics to restore the biodiversity of the gut microbiota and improve patient resistance to CDI or its recurrence, according to Mary Butler, Ph.D., of the division of health policy and management, University of Minnesota School of Public Health, and her associates.
CDC/Jennifer Hulsey
This illustration depicts the ultrastructural morphology exhibited by a single Gram-positive Clostridium difficile bacillus.
Since publication of the original review, data have been reported supporting the effectiveness of new diagnostic tests, as well as the comparative efficacy of particular agents over others in different stages of the illness. Dr. Butler and six additional experts in the fields of health policy and management and infectious disease reviewed published literature from 2010 through 2015 focusing on a limited number of quality improvement opportunities identified as most important to improve patient care, adding seven new findings and updating six findings from the original review.
To update the 2011 review, the authors conducted a literature review covering the years 2010 through 2015. Of the 7,416 individual citations identified using this search methodology, 252 were selected for further scrutiny. Of these, 37 diagnostic studies and 56 studies evaluating prevention or treatment interventions were identified and assessed from a pool of 252 eligible studies selected from 7,416 citations regarding early diagnosis, prevention, and treatment of Clostridium difficile.
Dr. Butler and her colleagues noted that the four years between the original review and the update were marked by an overall increase in research regarding both diagnosis and interventions. Aside from the aforementioned interventional updates, four diagnostic methodologies without recommendations in the original review (nucleic acid amplification tests, enzyme tests for toxins A/B, assay tests for glutamate dehydrogenase, and test algorithms) are all included in the update, with high, moderate, and low levels of evidence, respectively.
Regarding preventive strategies, the design and reporting of new studies published since the release of the original review were considered to have shown improvement; however, only weak evidence was found for effectiveness in reducing the incidence of CDI.
The updated management review has been published online at www.effectivehealthcare.ahrq.gov/reports/final.cfm (AHRQ Publication No. 16-EHC012-EF. March 2016).
The Agency for Healthcare Research and Quality funded the update. None of the investigators reported any affiliations or financial involvements that would have conflicted with the material presented in this report.