Treatment of First Recurrences of Clostridium difficile-Associated Disease: Waiting for New Treatment Options

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Abstract
In this issue of the journal, Pepin et al. [1] have reported on the outcomes of treatment of 463 first recurrences of Clostridium difficile-associated disease (CDAD) during the period of 1991 through mid-2005, spanning the period prior to and during the outbreak of infection with the C. difficile ribotype 027/NAP-1 pulsotype strain in Sherbrooke, Quebec. Almost two-thirds of the recurrences occurred in the outbreak period 2003–2005. A major question arising in the infectious diseases community is whether and when to abandon the use of metronidazole as first-line therapy for C. difficile diarrhea, both for initial and recurrent episodes in the face of the changing epidemiology of this reemerging infectious disease [2, 3]. Earlier this past year, Pepin et al. [4] and Musher et al. [5] reported their recent findings of higher relapse rates and delayed or suboptimal responses for metronidazole treatment of initial episodes of CDAD. The implication by extrapolation was that metronidazole should be abandoned in favor of vancomycin. The accompanying editorial by Gerding [6] cautioned that these clinical experiences are still subject to uncontrolled biases, that carefully conducted randomized trials are required to resolve the relative merits or deficiencies of treatments, and that metronidazole should remain the agent of choice for the majority of cases of initial treatment.