Treatment of recurrent Clostridium difficile-associated disease.

Recurrent Clostridium difficile-associated disease (RCDAD) is a difficult treatment problem--once a patient has one recurrence of the disease the likelihood of further recurrences is markedly increased. Repeat antibiotics are usually indicated, either metronidazole or vancomycin. Tapering and pulsing the antibiotic dose after a 10-day standard course decreases the incidence of recurrences compared with abruptly stopping antibiotics after a simple 10-day course. If recurrences continue after two courses of metronidazole, vancomycin may be preferable to avoid the risk of neurotoxicity that is associated with prolonged metronidazole use. There is also a role for probiotics in the treatment of RCDAD; Saccharomyces boulardii has been shown to decrease recurrences by about 50%, especially when combined with high-dose vancomycin. Other microbiologic approaches include the restoration of normal colonic flora by fecal enema or by nasogastric tube, but these have not been studied in controlled trials. In addition, there are numerous new treatment approaches that are under development, including a vaccine, which promise to aid the future treatment of RCDAD as well as prevention of initial CDAD.