How Do We Win the War Against Clostridium difficile Infection?

Statistics help tell the disturbing story: While Clostridium difficile (C diff) infections are on the rise, treatment choices have been limited.¹ In 2011, C diff was responsible for 29,000 deaths in United States.² 

To add insult to injury, more than 60% of patients experience additional episodes of C diff infection after a first recurrence.¹ And 25% of those infected will develop a recurrence.² Finally, C diff in hospitalized patients has an overall mortality rate of 23% at 30 days.³ Extrapolating the statistics to dollars and cents, in 2010, C diff management in the United States alone totaled $1 billion.³ Do we have better weapons than the present standard therapy?

After metronidazole and vancomycin, fidaxomicin was introduced, costing approximately $2800 for a 10-day therapeutic course.³ Another therapy—fecal microbiota transplantation³—seems to offer considerable benefit to people with C diff infections, despite logistic difficulties in its application. Bluntly described, fecal microbiota transplantation is the transfer of “normal colonic flora” from homogenized donor stool, into recurrently C diff-infected recipients.

Microbiota transplantation has 90% efficacy in resolving recurrent C diff infections!³ So why hasn’t it been used more during our burgeoning C diff epidemic?

Donors must be identified and screened appropriately.² Who pays for screening?² Who pays for the procedure, which usually is done during a colonoscopy?² What about a new look at applying this procedure more efficiently?

This month’s Top Paper takes and different and promising direction.¹ Frozen, stored stool as potential microbiotic transplantation material was tried (by way of enema, not colonoscopy) in adults who experienced recurrent C diff infections. The frozen treatment was not inferior to the previous gold standard of fresh donor stool. Switching to approved, reliable frozen samples will eliminate many logistic hurdles which previously had been a road block to this transplantation technique.²

Added to the Top Paper’s editorial comment is a wise caveat that we have been all too slow to learn: C diff infection is a “punishment” for our less-than-acceptable antibiotic stewardship. Be careful out there!

Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the Consultant editorial board.

References:

1. Lee CH, Steiner T, Petrof EO, et al. Frozen vs fresh fecal microbiota transplantation and clinical resolution of diarrhea in patients with recurrent Clostridium difficile infection: a randomized clinical trial. JAMA. 2016;315(2):142-149.
2. Malani PN, Rao K. Expanded evidence for frozen fecal microbiota transplantation for Clostridium difficile infection: a fresh take. JAMA. 2016;315(2):137-138.
3. Austin M, Mellow M, Tierney WM. Fecal microbiota transplantation in the treatment of Clostridium difficile infections. Am J Med. 2014;127(6):479-483.