Introduction

Clostridiodes (formerly Clostridium) difficile associated diarrhea (CDAD) is the most common cause of hospital acquired diarrhea in Canada, and is increasingly associated with community acquisition. CDAD pathogenesis requires gut colonization with the organism, in addition to loss of competitive microflora due to antibiotic treatment. CDAD is defined as diarrhea, in the presence of a positive stool toxin test, or endoscopic evidence of pseudomembranous colitis.

The most effective treatment of recurrent CDAD is replacement of gut microflora through fecal microbiota transplantation (FMT) delivered orally or rectally.

However, FMT is not available in Newfoundland and Labrador to date.

Fidaxomicin has demonstrated equal CDAD clinical cure rate, and superior prevention of relapse, compared to oral Vancomycin.

Despite evidence that relapse prevention makes Fidaxomicin cost effective for first line treatment, the Newfoundland and Labrador Prescription Drug Plan provides funding for Fidaxomicin only for the third CDAD episode, or for Vancomycin failure or intolerance.

Most CDAD treatment occurs in hospital with an average length of stay of approximately 21 days after positive stool test, so outpatient insurance coverage is often not relevant.

Fidaxomicin has been added to the Eastern Health formulary in 2018. Use is not restricted to infectious diseases consultation.

The evidence for benefit of oral probiotics in treatment or prevention is not adequate.