Fidaxomicin "Chaser" Regimen Following Vancomycin for Patients With Multiple Clostridium difficile Recurrences

TO THE EDITOR—Fidaxomicin has been shown to be effective for treating patients with primary Clostridium difficile infection (CDI) and patients with a first recurrence of CDI [1]. Treatment of patients with multiple CDI recurrences may be more challenging and require other strategies. We hypothesized that using fidaxomicin in a post-vancomycin “chaser” strategy might be effective in breaking the cycle of multiple CDI recurrences. Vancomycin is predictably effective in clearing both the organism and its toxins in the stool of patients following treatment for 1 week or less [2]. Despite efficacy of vancomycin against the vegetative state of C. difficile, recurrences after treatment completion are common, presumably due to germination of residual spores. We previously showed that a 2-week course of rifaximin following a course of vancomycin when the patients were asymptomatic (and presumably when the infectious inoculum of C. difficilewas low) was effective in stopping recurrences in many patients with multiple CDI episodes [3, 4]. Three patients in our clinic had failed multiple attempts to interrupt recurrences of CDI and were maintained on lowdose vancomycin until fidaxomicin became available (Table 1). These patients, aged 80 (female), 32 (female), and 67 (male) years had recurrent CDI episodes over a period of 24, 30, and 8 months, respectively. All of them had been initially treated with metronidazole followed by vancomycin and a tapering/