Clinical Overview: C. Difficile Infection and Treatment Options - Pharmacy Times

Clostridioides difficile (C. diff) is a type of bacterium that can cause infection, especially in the large intestine or colon. Such infections can cause various symptoms, such as diarrhea, and in severe cases, life threatening damage to the colon. The disease caused by C. diff mostly happens after antibiotic use. It can affect elderly populations who are either hospitalized or living in long-term care facilities.1

C. diff is type of gram-positive drumstick shaped bacteria that produces toxins in the person's body. It is usually found in air, water, human and animal feces, and in soil. It is also found in surfaces, especially in the hospital settings.

However, the main route of transmission is through the fecal-oral route. When transmitted, it starts producing toxins in those individuals taking long term antibiotics or prone to such infections.2

The main cause of C. diff infection (CDI) remains antibiotic use and overuse. Such antibiotics include penicillin, cephalosporins, fluoroquinolones, and clindamycin. Taking these antibiotics for an extended duration causes the good bacteria in the body to die, and therefore giving permission to C. diff bacteria to replicate, grow, and infect.

Besides antibiotics, being elderly or taking high-risk medication regimens such as chemotherapy can lead to CDI as well. Further, chronic renal failure and long-term use of proton pump inhibitors can also cause CDI.2

In the United States, there are approximately 200,000 people who are infected by C. diff every day in acute care settings. Out of these patients, approximately 12,000 individuals die from CDI.3

The mild infection may cause diarrhea and cramping, and lead to increased heart rate, fever, dehydration, nausea, kidney failure, swollen abdomen, and loss of appetite. When it is severe, CDI can also inflame the intestinal tract and cause enlargement of colon, as well as sepsis.2

Diagnosis of CDI includes assessing the presence of diarrhea, signs and symptoms of infection, and testing stool samples, especially when it is suspected. In some cases, sigmoidoscopy or colonoscopy can help check for inflammation or abnormal tissue in the colon. CT scans and X-rays may help identify thickening of the colon wall, enlargement of the bowel, and identify any perforation in the lining of the colon.2

To prevent the spread of CDI, there are various infection control strategies that health care professionals and patients can implement. These steps include avoiding unnecessary use of antibiotics, if possible. The more narrow-spectrum antibiotics that are used for the most appropriate infections that are identified, the better the outcome will be. Using soap and water to wash hands properly and regularly can help prevent the spread of CDI tremendously.

This is recommended for health care professionals, patients and their caretakers. Related to hand washing, maintaining hand hygiene with the use of hand sanitizers on a regular basis can help prevent the infection.

Another strategy includes contact precautions, such as wearing gloves and isolation gowns, especially with patients diagnosed with the C. diff bacteria. Finally, disinfecting the areas impacted by C. diff on a regular basis with the proper disinfecting products, including bleach, can help stop the spread of CDI.2

Treatment for CDI includes the use of antibiotics, such as vancomycin (Vancocin) and fidaxomicin (Dificid). Proper and prompt identification of the infection and starting the antibiotic is key for successful antibiotic therapy. Antibody-based therapy, such as the use of bezlotoxumab (Zinplava), could be another option, especially in those with high risk of CDI recurrence.

Fecal microbiota transplant (FMT), as known as stool transplant, is another treatment option that has recently emerged in fighting against CDI. Recently, the FDA approved the first FMT to be used for the treatment of CDI.

The new FMT approved by FDA is called Reybota (fecal microbiota) from Ferring Pharmaceuticals. Patients approved for use of Reybota need to sign an informed consent about the benefits and risks of this experimental procedure.

FMT restores the health bacteria when placed from the donor's stool into the C. diff-infected person's colon. The stool sample is delivered from a stool bank, such as the non-profit OpenBiome. The donor sample can be placed in the receiving body in many ways, including through colonoscopy.4

Lastly, using probiotics as supplements can help improve the good bacteria in the body. Even though these probiotics are not extensively studied, proper use according to a primary care physician's recommendation can help the colon's overall health for the long term.2

Knowing that CDI can turn deadly, many patients have various options to stop the infection and prevent it from reoccurring. It is left to the health care providers to promote the routine preventive measures and to find the best ways to routinely educate the patient population on fighting against CDI.

References

1. C. difficile infection (2021) Mayo Clinic. Mayo Foundation for Medical Education and Research. Available at: https://www.mayoclinic.org/diseases-conditions/c-difficile/symptoms-causes/syc-20351691 (Accessed: March 29, 2023).

2. Clostridioides difficile - statpearls - NCBI bookshelf (no date). Available at: https://www.ncbi.nlm.nih.gov/books/NBK431054/ (Accessed: March 29, 2023).

3. Clostridioides difficile infection (2019) Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/hai/organisms/cdiff/cdiff_infect.html#:~:text=How%20common%20are%20these%20infections,%3A%202019%20AR%20Threats%20Report%5D. (Accessed: March 29, 2023).

4. Glasgow, E. (2022) FDA approves first FMT therapy and issues guidance, American Gastroenterological Association. Available at: https://gastro.org/news/fda-approves-first-fecal-microbiota-transplantation-therapy/#:~:text=FDA%20approves%20first%20FMT%20therapy%20and%20issues%20guidance%20%2D%20American%20Gastroenterological%20Association (Accessed: March 29, 2023).

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