New guidelines were recently published in Clinical Infectious Disease regarding updates in the diagnosis and management of infections caused by C. difficile colitis (LINK), which is an infectious syndrome caused by a bacterial organism that interestingly proliferates in the colon of humans when recent antibiotic exposure destroys other bacteria that are present within the gut. This results in profuse diarrhea, colonic inflammation, and in more serious cases, the possibility of ileus, megacolon, colonic perforation, sepsis and even death. Prior to this, the last updated guidelines were published in 2010. Although many of the diagnostic and management recommendations have remained unchanged, a number of key points are worth noting in the new guidelines, when compared to the 2010 recommendations:
Flagyl is no longer recommended as first line therapy for the treatment of non-severe and severeC.difficile infection in adults: Oral vancomycin or oral fidoxamicin are now the recommended first line drugs. This is based on prior studies that have shown improved cure rates for C.difficile infection among those patients who took these drugs, when compared to oral Flagyl. Moreover, given the larger chemical structures of oral vancomycin and fidoxamicin when compared to Flagyl, the latter 2 drugs are more likely to remain in the colon after they are consumed, attributing to their higher curative success rates. For first and second recurrences of C.difficile, oral vancomycin and fidaoxamicin should be used instead of Flagyl as well, however for children, Flagyl still remains an option for initial as well as recurrent episodes of C.difficileinfection (more on this below).
Fecal Microbiota Transplantation (FMT) for all with 2 or more recurrences of C.difficile infection: A number of studies have been published since the prior guidelines from 2010 emphasizing the efficacy of FMT. FMT involves the transference of a healthy person’s stool into an individual with ongoing issues with C. difficile colitis, in an effort to re-establish the normal microbiome of the gut of the infected individual. Although this used to be done through placement of a nasogastric tube or via colonoscopy, there are less invasive methods available, including oral capsule administration, that make the transplant process cheaper, less risky and more tolerable. It is not approved yet by the FDA, but they do have guidelines regarding the utility of FMT among patients who do not respond to standard C.difficile therapy.
Guidelines for children with C.difficile are now included: The new guidelines do incorporate the diagnosis and management of C.difficile infections in children, both for initial and subsequent infections, and also has some recommendations on the utility of FMT for children who have recurrent C.difficile infections. However, the quality of evidence to support the recommendations made is still moderate to very low, and more research is still needed to make more definitive recommendations in the pediatric population
The best testing scheme for C.difficile? Depends on where you work: The diagnostic test of choice forC.difficile infection is still PCR testing of the toxin from the stool, however given the high sensitivity of this test, for institutions in which there is no agreement among clinical and laboratory personnel in not submitting stool specimens from patients less likely to have C.difficile (<3 unformed stools in 24 hours, patients on laxitives), a multi-step algorithim (glutamate dehydrogenase or EIA toxin testing along with PCR toxin testing) is recommended.
There were no recommendations on the use of probiotics in the setting of being treated for C.difficile infection, nor was there any recommendation on discontinuing proton pump inhibitor therapy as a measure of reducing the risk for C. difficile, as very little data was available to make recommendations on these topics. In addition, although available for C.difficile therapy, the new monoclonal antibody against toxin A of C.difficile (bezlotoxamab, see our previous post on this here) was not mentioned given lack of any longitudinal data on this treatment as of now. Recommendations on epidemiological and infection control methods to curtail C.difficile infection in hospitals remainder similar to what was mentioned in the 2010 guidelines as well.
Although the new guidelines are useful in helping to diagnose and manage C.difficile infection, the best way to prevent this infection still involves avoiding antibiotic use in patients who do not need them. The notion that every set of infectious symptoms needs antibiotics in order to improve is flawed, and patients often do not realize that antibiotics have real consequences associated with them. Physicians need to be aware of this in order to help change the culture of antibiotic overuse that pervades our healthcare system; at the very least, providers should refer patients to qualified infectious disease physicians who can help guide treatment for infections if and when it is indicated.
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