Clinical Report: Clinician Preferences in Managing Adult Clostridioides difficile Infection
Overview
A 2024 survey of 500 infectious diseases clinicians revealed that vancomycin remains the most frequently prescribed initial therapy for nonfulminant CDI despite guideline preferences for fidaxomicin. Significant barriers such as insurance coverage and high costs limit the use of fidaxomicin, bezlotoxumab, and microbiome-based therapies including fecal microbiota transplantation (FMT).
Background
Clostridioides difficile infection (CDI) is a major cause of morbidity and mortality, with updated 2021 IDSA/SHEA guidelines recommending fidaxomicin over vancomycin for initial and recurrent episodes due to lower recurrence rates. Bezlotoxumab is advised as adjunctive therapy to reduce recurrence risk in select patients. New microbiome-based therapies, including FDA-approved fecal microbiota live-jslm and spores live-brpk, have expanded options for preventing recurrent CDI. However, adoption of these therapies is influenced by cost, insurance barriers, and availability.
Data Highlights
Parameter
Percentage (%)
Numerator/Denominator
Vancomycin as most frequently prescribed initial agent
Barrier to fidaxomicin use: outpatient insurance coverage issues
82
408/496
Bezlotoxumab availability
74
370/500
Clinicians not routinely using bezlotoxumab
33
165/497
Clinicians recommending FMT for recurrent CDI
87
437/500
Current access to FMT using donor stool
48
239/500
Availability of fecal microbiota live-jslm (Rebyota)
36
179/500
Availability of fecal microbiota spores live-brpk (Vowst)
30
150/500
Key Findings
Vancomycin remains the predominant initial treatment for nonfulminant CDI despite guideline preference for fidaxomicin.
Institutional guidelines frequently recommend vancomycin as first-line therapy (72%).
Insurance coverage challenges are the most common barrier to fidaxomicin use (82%).
Bezlotoxumab is available to most clinicians (74%) but one-third do not use it routinely.
Most clinicians have recommended FMT for recurrent CDI, but less than half currently have access to donor stool FMT.
New microbiome-based therapies have limited availability, with 36% and 30% reporting access to fecal microbiota live-jslm and spores live-brpk, respectively.
Clinical Implications
Clinicians should be aware that despite guideline recommendations favoring fidaxomicin and adjunctive bezlotoxumab, practical barriers such as cost and insurance coverage significantly influence prescribing patterns. Efforts to improve access to microbiome-based therapies and FMT could enhance management of recurrent CDI. Awareness of institutional guideline variations may also inform treatment decisions.
Conclusion
This survey highlights a gap between guideline recommendations and real-world clinical practice in CDI management, largely driven by economic and logistical barriers. Addressing these challenges is essential to optimize treatment outcomes for adult patients with CDI.
References
IDSA/SHEA Guidelines 2021 -- Clinical Practice Guidelines for Clostridioides difficile Infection
FDA Approvals 2022-2023 -- Rebyota and Vowst for Recurrent CDI Prevention
Emerging Infections Network Survey 2024 -- Preferences of Clinicians in Managing Adult CDI
