A New Approach to Treatment-Resistant C difficile Infection

Finding safe and effective treatments for resilient Clostridioides difficile infection (CDI) remains an uphill battle.

While there are powerful antibiotics that can clear CDI, these often kill good gut bacertia alongside the bad. Thus, if the highly resistant C diff resurges (about 20-30% of CDI patients will have a recurrence), the bacteria can flourish with no competition, becoming even more lethal.

Fecal microbiota transplant (FMT) is an alternative option to combat the cycle of C difficile infection and recurrence. Recurrent CDI patients are given stool from a healthy donor, via endoscopy, enema, or capsule. If successful, the gut microbiota is repopulated with a healthy variety of bacteria once again.

This article was originally published on PharmacyTimes.com

Researchers have created an ideal protocol to ensure that fecal microbial transplant treatments are successful for patients with treatment-resistant, recurrent CDI. The team outlined a case report to demonstrate their findings, which were published in Case Reports in Gastroenterology.

The authors noted that timing appears to be a pivotal factor when considering a fecal transplant.

“While there is currently limited literature on the ideal timing and duration of antibiotic administration prior to fecal microbial transplant, there is vastly sufficient evidence supporting the efficacy of fecal microbial transplants when administered properly,” the study authors wrote.

After a fecal transplant, 65% to 80% of patients were cured of recurrent C difficile, according to a supporting study. After multiple treatments, 90% to 95% of these patients were fully cured.

In 2011, the common condition of C difficile colitis affected 500,000 individuals in the United States, but it’s impact may be bigger today. Symptoms of C difficile can include profuse and watery diarrhea, bloody diarrhea, bloat, and weight loss. Most patients are prescribed a course of antibiotics (p.o. vancomycin, fidaxomicin, or metronidazole); however, 15% to 30% of patients may experience recurrent colitis.

Fecal microbial transplants are an alternative treatment for patients experiencing recurrent symptoms from antibiotic resistance. In a transplant, the patient receives donor fecal material that aims to improve their gut microbiome. The procedure is widely used in refractory cases, but data on timing and real-world practices remain limited.

Researchers conducted a case report on a 36-year-old male patient to provide evidence of how a transplant can be a successful treatment option. The participant dealt with recurrent CDI for 2 years after being on an antibiotic from tooth extraction.

Daily C difficile symptoms would include up to 20 loose bowel movements every day, abdominal cramping, bloating, poor sleep, rectal pain, anal fissures, and an unhealthy 25-pound weight loss. The patient received 12 courses of antibiotics, but none eradicated the CDI.

Upon choosing to receive a fecal transplant, the patient took:

• 14-day course of fidaxomicin 200 mg p.o. in the morning
• 14-day course of cholestyramine 4 mg p.o. each evening.
• Daily yogurt and probiotic supplementation

The patient then received the transplant and although he showed some symptoms of CDI, follow-up testing returned negative for C difficile. The patient regained weight, had improved quality of life, and has not been reinfected.

The proposed systematic treatment approach is intent on reducing bacterial and spore load using antibiotics and spore-binding agents before receiving the transplant. Reducing bacterial and spore load prior to transplant could ensure the timeliest remission and reduce chances of recurrence.

“It may prove highly beneficial to equip providers with literature that exemplifies proper medication administration prior to fecal microbial transplants with the goal of improving cure rates in patients after one fecal microbial transplant,” the authors wrote.

Reference

Gangadhar, M., Kottapalli, A., Kottapalli, V., et al. A Novel Treatment Approach to Treatment-Resistant, Recurrent Clostridium difficile. Case Rep Gastroenterol 2022;16:637–642. https://doi.org/10.1159/000527854