Introduction: Updating data on Clostridioides difficile antibiotic resistance is important for treatment improvement of C. difficile infections (CDIs).
Areas covered: Results from 20 countries were included. The mean resistance to 2 mg/l vancomycin, 2 mg/l metronidazole, 4 mg/l moxifloxacin, and 4 mg/l clindamycin was 4.7% (0 to ≥ 26% in two studies), 2.6% (0 to ≥ 40% in 3 studies), 34.9% (6.6->80%), and 61.0% (30->90%), respectively. Resistance to erythromycin (>60-88%), rifampin (>23-55.0%), imipenem (0.6 to > 78% in a clone), tigecycline (0-<5.0%), and fidaxomicin (0-2%) was also found. Resistance to ≥ 5 antibiotics of different classes was reported in some countries. High resistance and multidrug resistance were observed in hypervirulent and epidemic strains. Although only 1% of COVID-19 patients had CDIs, the proportion might be underestimated.
Expert opinion: C. difficile antimicrobial susceptibility varied by country/region, study period, and circulating ribotypes. For CDI treatment, fidaxomicin (preferably) or vancomycin is recommended, while metronidazole is suitable for mild infections. New approaches, including biotherapeutics (Rebyota), strains, antibiotics (ridinilazole and ibezapolstat), and monoclonal antibodies/cocktails merit further evaluation. Because of the resistance rate variations, C. difficile antibiotic susceptibility should be regularly monitored. Post-COVID-19 resistance should be separately presented. Some discrepancies between vancomycin and metronidazole results need to be clarified.
Keywords: Antibiotic; Clostridioides difficile; Clostridium difficile; hypervirulent; multidrug resistance; resistance; ribotypes; treatment.
Clostridioides difficile can cause mild to dangerous diarrhea in people following antibiotic use. Many antibacterial agents can cause diseases. However, treatment is limited to three antibiotics. The study of resistance to them is important for improving the treatment of infections. The study of resistance to other antibiotics helps to understand the spread and risks of infections. We discussed data about C. difficile antibiotic resistance from 20 countries according to recent publications. For the treatment of C. difficileinfections, fidaxomicin is the drug of choice with 0–2% resistance to it. Resistance to the two other antibiotics used to treat infections is less than 5% of isolates. Much higher resistance was found to antibiotics that can cause C. difficile infections such as ciprofloxacin, clindamycin, ceftriaxone, erythromycin, and others. The resistance varies according to the country, patients’ groups, years of study, and circulating strains. The resistance was high in hypervirulent and epidemic strains. In some studies, there was resistance to 5 and 6 antibiotics of different classes. Antibiotic use and incidence of infections during the COVID-19 pandemic varied. However, the evolution of C. difficile infection during the pandemic has yet to be determined.