It’s time to rethink your approach to C diff infection
Metronidazole is no longer the drug of choice for first-line therapy. And fecal microbiota transplantation has proven effective for certain patients.
PRACTICE RECOMMENDATIONS
› Keep in mind that previous exposure to antibiotics is the most important risk factor for initial and recurrent Clostridioides difficile infection (CDI). Thus, appropriate antimicrobial stewardship is key to prevention. C
› Begin with vancomycin or fidaxomicin (over metronidazole) for first-line treatment of CDI in adults. A
› Consider fecal microbiota transplantation in high-risk patients with recurrent CDI for whom antimicrobial therapy has failed. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
When meds fail, consider a fecal microbiota transplant
Another important change in the IDSA guidelines for CDI management is the strong recommendation for fecal microbiota transplantation (FMT) in patients with multiple recurrences of CDI for whom appropriate antibiotic treatment courses have failed.11,25 The goal of FMT is to “normalize” an abnormal gut microbiome by transplanting donor stool into a recipient.26
FMT has been shown to be highly effective in 5 randomized clinical trials conducted since 2013, with CDI cure rates between 85% and 94%.11 This rate of cure is particularly impressive given that the studies only included patients with refractory CDI.
Patients with recurrent CDI who may be candidates for FMT should be referred to a center or specialist with experience in FMT. These transplants can be expensive because of the screening process involved in obtaining donor samples. (Historically, a single FMT has cost $3000-$5000, and it is seldom covered by insurance.27) The emergence of universal stool banks offers a streamlined solution to this process.26
Fresh or frozen stool is considered equally effective in treating refractory CDI.26 Oral capsule and freeze-dried stool formulations have been studied, but their use is considered investigational at this time.26
Delivery via colonoscopy to the right colon is the preferred route of infusion; however, delivery via enema or nasogastric, nasojejunal, or nasoduodenal infusion can be considered as well.26
Continue to: In preparing for stool transplantation...
