, Volume 42, Issue 1, pp 43–59 | Cite as

Treatment of recurrent Clostridium difficile infection: a systematic review

  • J. C. O’Horo
  • K. Jindai
  • B. Kunzer
  • N. Safdar
Clinical and Epidemiological Study



Clostridium difficile infection (CDI) recurs in nearly one-third of patients who develop an initial infection. Recurrent CDI (RCDI) is associated with considerable morbidity, mortality, and cost. Treatment for RCDI has not been not well examined.


A systematic review.


Sixty-four articles were identified evaluating eight different treatment approaches: metronidazole, vancomycin, fidaxomicin, nitazoxanide, rifampin, immunoglobulins, probiotics, and fecal bacteriotherapy. The meta-analysis found vancomycin to have a similar efficacy to metronidazole, although studies used varying doses and durations of therapy. Fidaxomicin was slightly more efficacious than vancomycin, though the number of studies was small. Good evidence for probiotics was limited. Fecal bacteriotherapy was found to be highly efficacious in a single randomized trial.


Metronidazole and vancomycin have good evidence for use in RCDI but heterogeneity in treatment duration and dose precludes robust conclusions. Fidaxomicin may have a role in treatment, but evidence is limited to subgroup analyses. Fecal bacteriotherapy was the most efficacious. Saccharomyces boulardii may have a role as adjunctive treatment.


Recurrent Clostridium difficile Clostridium difficile Treatment Antibiotic Immunoglobulin Fecal bacteriotherapy 



The authors would like to thank librarian Mona K. Stevermer for her assistance with the literature search.

Conflict of interest

None of the authors have any relevant conflicts of interest to disclose.

Supplementary material

15010_2013_496_MOESM1_ESM.pdf (34 kb)
Supplementary Appendix 1 (PDF 35 kb)
15010_2013_496_MOESM2_ESM.doc (106 kb)
Supplementary Appendix 2 (DOC 103 kb)


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Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • J. C. O’Horo
    • 1
  • K. Jindai
    • 2
  • B. Kunzer
    • 2
  • N. Safdar
    • 2
    • 3
  1. 1.Section of Pulmonary and Critical Care Medicine, Department of MedicineMayo ClinicRochesterUSA
  2. 2.Section of Infectious Diseases, Department of MedicineUniversity of Wisconsin School of Medicine and Public HealthMadisonUSA
  3. 3.William S. Middleton VA HospitalMadisonUSA

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