Clostridioides difficile infection is a highly contagious disease that affects 500,000 people in the U.S. and results in nearly 30,000 deaths per year.1 In fact, as the most common healthcare-associated infection in U.S. hospitals, the U.S. Centers for Disease Control and Prevention has labeled it an urgent public health threat.2,3 Caring for patients with this infection can be challenging due to the risk of recurrence associated with the current standard of care, potential for progression to severe disease, and limited treatment options available.
One of the most significant challenges C. difficile infection presents is its tendency to come roaring back after initial diagnosis and treatment, beginning a vicious cycle of recurrence. In up to 35 percent of initial cases, recurrence occurs within 8 weeks of diagnosis and up to 65 percent of those patients go on to experience additional recurrences.4,5 Among people with recurrent C. difficile infection, up to 84 percent are hospitalized within one year, with an average of about two separate hospitalizations per patient.6,7
Antibiotics are the go-to treatment for C. difficile infection8,9 with physicians generally prescribing a 10-day course.10,11,12 If the infection returns, they may extend antibiotic treatment for several weeks. While antibiotic treatment may be effective in managing a C. difficile infection, paradoxically it is a risk factor for recurrence. Although antibiotics can wipe out disease-causing bacteria in the body, particularly in the intestines, they can also destroy helpful bacteria living in the gut. 13,14
Because antibiotics can kill off protective bacteria along with those that cause disease, using them may disrupt the delicate balance of microbes in the gut microbiome. This can lead to a state of imbalance called dysbiosis, which has been associated with a range of gastrointestinal diseases, such as irritable bowel syndrome and inflammatory bowel disease. When dysbiosis occurs, it may give harmful bacteria the chance to take hold and grow in the gut. This includes any C. difficile that may not have been wiped out in a previous round of treatment. This is how the cycle of recurrence can begin.14,15
Not only can continued rounds of antibiotics degrade the microbiome, they can also lead to other challenges, including antibiotic resistance. After completing a course of antibiotic treatment, practitioners may offer patients fecal microbiota transplantation (FMT), which is designed to add a diverse mix of microbes back to the gut.15 However, FMT is not approved as a treatment by the U.S. Food and Drug Administration and clinical studies, diagnosis, and treatment protocols are not standardized.16,17 Additionally, there have been case reports of infections with multidrug resistant pathogens with use of FMT products.18,19
As we continue to see C. difficile infection and recurrence among patients, it is clear that a new paradigm for treatment is necessary to break the cycle of recurrence of this vicious disease. The good news is that over the past decade, research on the gut microbiome and C. difficile infection has provided new insights into this complex illness so practitioners are better able to guide patients on their journey back to health. To get the full story on the microbiome, learn more about C. difficile infection and the challenges with current standards of care, visit www.PowerofMicrobiome.com.
1 Lessa FC, et al. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015;372(9):825-834.
2 Guh AY, Mu Y, Winston LG, et al. Trends in U.S. burden of Clostridioides difficile infection and outcomes. N Engl J Med. 2021;382(14):1320-1330.
3 Centers for Disease Control and Prevention website. 2021 Regulatory Oversight and Safety of Probiotic Use. https://wwwnc.cdc.gov/eid/article/16/11/10-0574_article. Accessed September 25, 2021.
4 Willing BP, Dicksved J, Halfvarson J, et al. A pyrosequencing study in twins shows that gastrointestinal microbial profiles vary with inflammatory bowel disease phenotypes. Gastroenterology. 2010;139(6):1844-1854.e1.
5 Cornely OA, Miller MA, Louie TJ, Crook DW, Gorbach SL. Treatment of first recurrence of Clostridium difficile infection: fidaxomicin versus vancomycin. Clin Infect Dis. 2012;55 Suppl 2(Suppl 2):S154-S161.
6 Mayo Clinic website. 2021 C. difficile – Diagnosis and treatment. https://www.mayoclinic.org/diseases-conditions/c-difficile/diagnosis-treatment/drc-20351697. Accessed September 25, 2021.
7 Rodrigues R, Barber GE, Ananthakrishnan AN. A comprehensive study of costs associated with recurrent Clostridioides difficile infection. Infect Control Hosp Epidemiol. 2017;38(2):196-202.
8 McDonald LC, Gerding DN, Johnson S, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66(7):e1-e48.
9 Johnson S, Lavergne V, Skinner AM, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA): 2021 Focused Update Guidelines on Management of Clostridioides difficile Infection in Adults. Clin Infect Dis. 2021;73(5):e1029-e1044.
10 DePestel DD, Aronoff DM. Epidemiology of Clostridium difficile infection. J Pharm Pract. 2013;26(5):464-475.
11 Knight CL, Surawicz CM. Clostridium difficile infection. Med Clin North Am. 2013;97(4):523-536.
12 Aukes L, et al. A risk score to predict Clostridioides difficile infection. Open Forum Infect Dis. 2021;8(3):ofab052.
13 Bien J, Palagani V, Bozko P. The intestinal microbiota dysbiosis and Clostridium difficile infection: is there a relationship with inflammatory bowel disease? Therap Adv Gastroenterol. 2013;6(1):53-68.
14 Staley C, Khoruts A, Sadowsky MJ. Contemporary applications of fecal microbiota transplantation to treat intestinal diseases in humans. Arch Med Res. 2017;48(8):766-773.
15 Leffler DA, Lamont JT. Clostridium difficile infection. N Engl J Med. 2015;372(16):1539-1548.
16 Tariq R, Pardi DS, Bartlett MG, Khanna S. Low cure rates in controlled trials of fecal microbiota transplantation for recurrent Clostridium difficile infection: a systematic review and meta-analysis. Clin Infect Dis. 2019;68(8):1351-1358.
17 Bafeta A, Yavchitz A, Riveros C, Batista R, Ravaud P. Methods and Reporting Studies Assessing Fecal Microbiota Transplantation: A Systematic Review. Ann Intern Med. 2017;167(1):34-39.
18 DeFilipp Z, Bloom PP, Torres Soto M, et al. Drug-Resistant E. coli Bacteremia Transmitted by Fecal Microbiota Transplant. N Engl J Med. 2019;381(21):2043-2050.
19 U.S. Food and Drug Administration. Important Safety Alert Regarding Use of Fecal Microbiota for Transplantation and Risk of Serious Adverse Reactions Due to Transmission of Multi-Drug Resistant Organisms. https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/important-safety-alert-regarding-use-fecal-microbiota-transplantation-and-risk-serious-adverse. Accessed May 25, 2022.