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Fidaxomicin in cdiff

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Fidaxomicin in cdiff

  1. 1. C. DIFF DIARRHEA: FIDAXOMICIN VS. VANCOMYCIN OVMC LANDMARK TRIALS SERIES Louie TJ, et al. "Fidaxomicin versus Vancomycin for Clostridium difficile Infection". The New England Journal of Medicine. 2011. 365(5):422-431.
  2. 2. Fidaxomicin versus Vancomycin for Clostridium difficile Infection
  3. 3. BACKGROUND  C. diff diarrhea is most common infectious entity in nosocomial diarrhea  Since 1990s>2x increase incidence of C.Diff  Relapse rates are high  New strains have emerged, including NAP1/BI/027 strain  Fidaxomicin is a macrocylic antibiotic and has more invitro activity against C.diff than Vancomycin  Fidaxomicin has limited systemic absorption and high fecal concentration
  4. 4. CLINICAL QUESTION How does Fidaxomicin compare to Vancomycin in terms of clinical cure for patients with Clostridium difficile-associated diarrhea?
  5. 5. DESIGN  Analysis: both modified intention-to-treat and per-protocol  Trial Design: Prospective, multicenter, double-blind, randomized, parallel-group trial  N=629  Fidaxomicin (n=302)  Vancomycin (n=327)  Setting: 52 US sites and 15 Canadian sites  Enrollment: May 2006 to August 2008
  6. 6. POPULATION Inclusion Criteria  Age ≥16 years  Diarrhea positive for C. difficile toxin within 48h prior to randomization Exclusion Criteria  Receiving other antibiotics effective against CDAD (eg, rifaximin)  Patients could receive ≤4 doses of metronidazole/vancomycin within 24h prior to randomization  Likelihood of death within 72 hours from any cause  Toxic megacolon  Past exposure to fidaxomicin  Pregnancy/breastfeeding  Inflammatory bowel disease  >1 C.diff occurrence within 3 months of study
  7. 7. INTERVENTIONS  Stratified according to whether current infection was FIRST EPISODE (primary occurrence) or SECOND EPISODE (first recurrence) within 3 months before study start  Received study medication orally each day for 10 days  Fidaxomicin 200mg PO q12h with intervening matching doses of placebo  Vancomycin 125mg PO q6h  Assessed daily for clinical cure or failure during 10-day course of therapy
  8. 8. CRITICISMS/LIMITATIONS/FUNDING  1st version of paper written by part-time employee of Optimer Pharmaceuticals  Fidaxomicin is noninferior in rate of clinical cure and does have moderate recurrence reduction, but is drastically more expensive (1 tab = $168, therapy course $3360)  No report of PPI use, a risk factor for severe C.diff recurrence  The treatment was mostly limited to the NAP1/BI/027 strain  Unclear antibody levels to C. difficile toxin A, a value that may relate to risk of recurrence  Excluded ill patients (eg patients with megacolon) FUNDING: Funded by Optimer Pharmaceuticals who manufactures Fidaxomicin
  9. 9. BOTTOM LINE This Phase 3 trial showed that Fidaxomicin was noninferior to vancomycin in achieving rates of clinical cure among patients with Clostridium difficile-associated diarrhea Fidaxomicin was associated with a significantly lower rate of recurrence of C. difficile infection associated with non-NAP1/BI/027 strain Guidelines -- IDSA/SHE CDAD (2010) Discontinue treatment with the antibiotic thought to be associated with CDAD occurrence as soon as possible (A-II) Start empirical treatment in severe or complicated CDAD as soon as suspected (C-III) Avoid antiperistaltic agents (C-III) Metronidazole 500 mg po TID for 10-14 days for initial episode of mild-to-moderate CDAD (A-I) Vancomycin 125 mg po QID for 10-14 days for initial episode of severe CDAD (B-I) Vancomycin 500 mg PO QID +/- metronidazole 500 mg IV q8h for severe, complicated CDAD (C-III) --If ileus, vancomycin 500 mg in 100 mL NS PR q6h as a retention enema ≥2nd CDAD recurrence with taper or pulse of vancomycin (B-III) Avoid metronidazole after the first recurrence of CDAD, including as a long-term agent, beacause of the risk of neurotoxicity (B-II)
  10. 10. BOARD-LIKE QUESTION A 41 yo woman is hospitalized for severe cellulitis. She is treated with Vanc/Zosyn, and discharged on PO Clindamycin. However, 5 days later he develops a fever and diarrhea, described as 5-8 liquid bowel movements over the last 24 hours. Medications include Metformin for DM2, Amlodipine for HTN. Physical exam: T 38, HR 107, BP 148/71 Abdomen: B+, soft, mildly tender diffusely Labs: WBC 18K, Creatinine 1.7 (baseline 0.9) Stool PCR shows C.diff Which of the following is the most appropriate treatment? A. Oral Metronidazole B. Oral Fidaxomicin C. IV Vanc + IV Metronidazole D. Oral Vanc + IV Vanc E. Oral Vanc + Oral metronidazole
  11. 11. BOARD-LIKE QUESTION ANSWER Which of the following is the most appropriate oral treatment? A. Oral Metronidazole B. Oral Fidaxomicin C. IV Vanc + IV Metronidazole D. Oral Vanc + IV Vanc E. Oral Vanc + Oral metronidazole Educational Objective: Treat a severe case of Clostridium difficile infection. Key Point: - Severe Clostridium difficile infection should be treated with oral vancomycin. - Oral Fidaxomicin non-inferior to oral Vancomycin - Severe CDI is defined by the Infectious Diseases Society of America as a leukocyte count of 15,000/µL (15 × 109/L) or greater and a serum creatinine level greater than 1.5 times the baseline level
  12. 12. REFERENCES  Louie TJ, et al. "Fidaxomicin versus Vancomycin for Clostridium difficile Infection". The New England Journal of Medicine. 2011. 365(5):422- 431.  Brain, L. P. (n.d.). Fidaxomicin in C. difficile Diarrhea. https://www.wikijournalclub.org/w/index.php?tit le=Fidaxomicin_in_C._difficile_Diarrhea

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