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The bacterium Clostridioides difficile, often referred to as C. diff, earned its name because it was difficult to culture in a laboratory. This gut infection can also be difficult to manage, making the name just as apt in modern times. This is especially true for the 15% to 20% of people whose C. diff symptoms initially resolve, only to return within a few weeks after the treatment ends.
Each C. diff recurrence increases the likelihood of having another one.
However, in recent years, the Food and Drug Administration (FDA) has approved new microbiome therapeutics that dramatically help reduce the risk of recurrence.
Stage 1: Antibiotics for C. difficile
Before using newer microbiome therapeutics, healthcare professionals treat active C. diff infection with one of the following antibiotics.
Fidaxomicin (Dificid)
This newer antibiotic kills active C. diff bacteria. Unlike another antibiotic called vancomycin, fidaxomicin tends to spare healthy gut bacteria. Since more of the healthy gut microbiome remains intact after treatment, the risk of recurrence is lower than for C. diff treated with vancomycin.
Vancomycin (Vancocin, Firvanq)
This older antibiotic has been used for decades to treat both initial and recurrent C. diff infections.
However, in addition to killing active C. diff, vancomycin also reduces levels of beneficial gut bacteria. This decreased bacterial diversity can increase the risk of a C. diff reinfection. For that reason, the Infectious Disease Society of America and the European Society of Clinical Microbiology and Infectious Diseases both recommend using fidaxomicin instead of vancomycin. In contrast, because vancomycin costs less than fidaxomicin, the American College of Gastroenterology recommends either antibiotic.
Treatment considerations
Healthcare professionals weigh many benefits and risks when recommending antibiotics for recurrent C. diff infections. Among them:
- Cost: Vancomycin is available as a generic, making it less expensive than fidaxomicin.
- Prior treatment: For a recurrence, your healthcare professional will likely recommend a different antibiotic or a longer antibiotic regimen than the one used to treat your initial C. diff infection. So, if you were initially prescribed fidaxomicin, your healthcare professional might switch to vancomycin or use a longer course of fidaxomicin. Conversely, if you were initially treated with vancomycin, your healthcare professional might switch to fidaxomicin or use a longer course of vancomycin.
Stage 2: Restoring the gut microbiome after taking antibiotics to treat C. difficile
In people with healthy guts, a wide variety of beneficial bacteria secrete substances that prevent C. diff spores from becoming an infection. However, in people with a history of C. diff, the numbers and diversity of health-promoting gut bacteria are lower, which makes it easier for C. diff to reinfect the gut. Known as dysbiosis, this impaired microbiome may be the result of prior C. diff antibiotic treatment. It also may stem from past use of antibiotics, use of tobacco or alcohol, or a low-fiber diet, among other causes.
The following microbiome-based therapies help restore the diversity and number of gut bacteria to a healthy level. Once the healthy microbiome is reestablished, the healthy bacteria help to prevent C. diff spores from germinating into an active infection.
Enema therapy
Fecal microbiota, live-jslm (Rebyota) is a liquid made from the stools of healthy donors. The donors and their stools are extensively screened before the samples are used to create the liquid suspension. Fecal microbiota, live-jslm contains the full spectrum of gut microbes found in a healthy gut microbiome. In clinical trials, 70% to 80% of people who received this therapy were free of active C. diff eight weeks later, with results lasting for two years.
To receive the therapy, you first finish an appropriate course of antibiotics. On the day of the procedure, you lie on your side on a table. A healthcare professional inserts a tube five inches into your rectum. Then 5 ounces of material flows through the tube and into your rectum. You continue to lie on your side for 15 minutes after the procedure.
Capsule therapy
Similar to live-jslm, live-brpk (Vowst) is made from donor stool that has been purified of viruses, vegetative bacteria, parasites and fungal organisms. After this purification process, only health-promoting gut bacterial spores remain.
To receive the therapy, you first finish a course of antibiotics. You’ll take a small dose of a laxative. Then, the next day you start taking capsules. You take four capsules a day for three days. You take them first thing in the morning, on an empty stomach.
Fecal microbiota transplantation
The previous treatments were developed, in part, based on the success of fecal microbiota transplantation. However, unlike microbiome enema or capsule therapy, fecal microbiota transplantation is still considered experimental and only allowed by the FDA under certain circumstances known as enforcement discretion.
To receive a transplant, you need to identify someone willing to serve as a stool donor. The person undergoes a strict screening process. Some medical centers may have stool banks or access to donor stool. Once the donor is approved, the donor’s stool is collected, mixed with saline water and filtered. Then the stool mixture is transferred into your colon, most commonly through a thin, flexible tube with a small camera at the tip called a colonoscope.
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