UK – The UK’s National Institute for Health and Care Excellence (NICE) and Public Health England (PHE) have published a new jointly developed guideline on antimicrobial prescribing for Clostridioides difficile (C. difficile) infection.

Under the new recommendations outlined in the guidelines, advice for managing C. difficile infection in both community and hospital settings has also been included.

The guideline has made a change to current practice, recommending that the first-line choice of antibiotic for adults for a first episode of mild or moderate C. Difficile infection should be oral vancomycin rather than metronidazole.

In a statement, NICE said the change is based on evidence showing metronidazole had lower initial cure rates and higher recurrence rates compared to vancomycin.

Combined with cost-effectiveness evidence, this shows that using vancomycin was both more effective and less pricey compared to prescribing metronidazole in this setting.

In addition, the guidance recommends that for children and young people under the age of 18 years, treatment with an oral antibiotic for suspected or confirmed C. Difficile infection should be started by, or after advice from either a microbiologist, pediatric infectious disease specialist or pediatric gastroenterologist.

Fidaxomicin should also be offered as a second-line antibiotic for a first episode of mild, moderate or severe C. Difficile infection if vancomycin in ineffective, according to the new guideline.

Further recommendations relate to the choice of antibiotic for a further episode of C. Difficile infection within 12 weeks of symptom resolution and for a further episode of C. Difficile infection more than 12 weeks after symptom resolution.

According to NICE, approximately 20-30% of cases of antibiotic-associated diarrhea are due to C. Difficile infection – this makes it the primary cause of infectious diarrhea in hospitalized patients.

PHE data shows that, in 2019/20, there were around 13,000 reported cases of C. Difficile infections in acute trusts and clinical commissioning groups in England.

About C. difficile infections

C. diff (also known as Clostridioides difficile or C. difficile) is a germ (bacterium) that causes severe diarrhea and colitis (an inflammation of the colon).

It’s estimated to cause almost half a million infections in the United States each year. About 1 in 6 patients who get C. diff will get it again in the subsequent 2-8 weeks. One in 11 people over age 65 diagnosed with a healthcare-associated C. diff infection die within one month.

Symptoms might develop within a few days after you begin taking antibiotics and include severe diarrhea, fever, stomach tenderness or pain, loss of appetite and nausea.

Research regarding the disease has been aggressive according to a press release by University of Exeter, researchers have identified a gene responsible for producing a protein that helps bind the bacteria to the gut of patients that could potentially be used to produce a vaccine for the infection.

No vaccine for C. diff is currently in widespread use, although some toxin-based vaccines are being investigated.

In 2017, Sanofi ended its efforts to find a toxin-based C. diff vaccine after many years of work because of a low probability of success. The alternative to toxin-based vaccines is an adhesion-targeting approach, such as the one identified in the current study.

The findings could offer a new approach because the C. diff bacteria must bind to the gut to produce the toxin that causes the illness.

Investigators immunized mice with the CD0873 protein in isolation and found a “strong” immune response, according to the study.

After being exposed to C. diff, these mice were unaffected, whereas non-immunized mice became sick and lost an average of approximately 10% of their body weight.

Researchers at the University of Paris-Sud conducted the experiments and noted that mice develop antibodies when immunized with the CD0873 protein.

Other researchers then mapped the 3D molecular structure of CD0873 at high resolution using a high-brightness X-ray beam.

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