Rectal Fidaxomicin as Salvage Therapy in Fulminant Clostridioides difficile Infection After Total Colectomy: A Case...

Clostridioides difficile infection (CDI) is a significant cause of antibiotic-associated diarrhea and colitis, ranging from mild to severe and potentially life-threatening conditions, like fulminant colitis with toxic megacolon and bowel perforation. The 2021 guidelines from the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) recommend vancomycin and metronidazole for fulminant CDI (FCDI), with consideration of rectal vancomycin for cases with ileus. Fidaxomicin, though preferred for initial and recurrent CDI treatment, is not the first line for FCDI due to limited evidence. Fidaxomicin has a narrow spectrum of activity only targeting C difficile and spares the normal intestinal microbiota, which may contribute to its favorable outcomes.

Our case study involves a 79-year-old man with worsening symptoms post-amoxicillin/clavulanic acid use. Diagnosed with septic shock from C difficile and toxic megacolon, the patient started on oral vancomycin and metronidazole, followed by rectal vancomycin, per guidelines, also requiring vasopressors and renal replacement therapy. Despite initial treatment, his condition deteriorated, after which he underwent a sub-total colectomy without improvement. He was eventually started on rectal fidaxomicin and loperamide, resulting in rapid improvement. This case introduces rectal fidaxomicin as a novel approach for FCDI treatment with unique preparation and administration methods.

An extensive review of the literature found only a few instances of rectal fidaxomicin use for FCDI, suggesting its novelty and rarity. The successful outcome prompts further studies to validate its efficacy and its possible inclusion in future treatment guidelines. In summary, this case underscores the complexity of FCDI management and highlights the potential of rectal fidaxomicin as a salvage therapy. Further research is warranted to elucidate its role in treating FCDI and incorporating it into clinical practice guidelines.