Applied Evidence

It’s time to rethink your approach to C diff infection

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In preparing for stool transplantation, patients should be treated with standard doses of oral vancomycin or fidaxomicin for 3 days before the procedure to suppress ­intestinal C difficile, and the last dose of ­antibiotics should be given 12 to 48 hours before the procedure.26 Bowel lavage with polyethylene glycol is recommended, regardless of whether stool is delivered via colonoscopy or upper GI route.

Short-term adverse events associated with FMT appear to be minimal; data is lacking for long-term safety outcomes.28 While only recommended currently for cases of recurrent CDI, there is promising data emerging for use of FMT for severe cases, even without recurrence.29

The role of probiotics remains unclear

Probiotics have been explored in numerous trials to determine if they are effective in preventing CDI in patients who have been prescribed antibiotics.11 While no randomized trials have conclusively shown benefit, several meta-analyses have shown that the use of probiotics may result in a 60% to 65% relative risk reduction in CDI incidence.30,31

One proviso to these meta-analyses is that the incorporated studies have typically included patients at very high risk for CDI, and subanalyses have only found a reduction in CDI incidence when patients are at a very high baseline risk. In addition, there are many differences in probiotic types, formulations, treatment durations, and follow-up. As a result, the IDSA guidelines state that there is “insufficient data at this time” to recommend routine administration of probiotics for either primary or secondary CDI prophylaxis.11

Due to insufficient high-quality data, the IDSA guidelines do not provide a recommendation regarding use as an adjunct treatment option for acute CDI.11 Probiotics should not be routinely used to prevent CDI; however, they may provide benefit if reserved for patients at the highest risk for CDI (eg, history of CDI, prolonged use of broad-spectrum antibiotics, high local incidence).

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