T o the E ditor—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. difficile was 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 low-dose 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/pulsed vancomycin treatment strategy only to “break through” near the end of or shortly after their vancomycin taper, which ended with vancomycin given every second day followed by every third day. One patient had been given a rifaximin chaser on 2 occasions and intravenous immunoglobulin after failed attempts at vancomycin tapers (patient 3, Table 1). This patient reported long periods without symptoms after each rifaximin course (6–8 weeks), but eventually developed mucous stools with abdominal cramping and was retreated with vancomycin. One patient had been hospitalized with severe CDI following a slow vancomycin taper over a 5-month period (patient 2, Table 1). All 3 patients were left on vancomycin 125 mg daily or every other day until fidaxomicin became available.