Updated C. Diff. Guidelines Recommend Fecal Transplantation

The revisions address the excessive use of antibiotics in hospitals, and recommend diagnostic treatments—including fecal transplantation—to improve the care of patients with Clostridium difficile.

With nearly 500,000 people sickened each year to Clostridium difficile, and 15,000 to 30,000 deaths attributed to it, the first new guidelines since 2010 have been launched to reduce the prevalence of the bacterial infection.

C. diff. is the most common bug acquired in hospitals and costs more than $4.8 billion in hospitalizations alone, according to the Centers for Disease Control and Prevention.

The number of C. diff. cases plateaued in 2010, after reaching historic highs, but it has yet to decline in the United States, as it has in Western Europe, according to a study by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America and published this month in Clinical Infectious Diseases.

The overuse of antibiotics is seen as a key factor in C. diff. infections, the study said, because the drugs kill good bacteria in the gut, which allows C. diff. to flourish and cause cramps and diarrhea.

"We can better control this epidemic by learning how to use new treatments and diagnostics," said L. Clifford McDonald, MD, co-chair of the guidelines panel and associate director for science at CDC's Division of Healthcare Quality Promotion.

The new guidelines recommend C. diff. testing only on patients with new onset and unexplained diarrhea. While immunoassays were the most common diagnostics employed previously, molecular testing – which has its pros and cons – is now used by more than 70% of hospital labs. Molecular tests can help rule out C. diff. infection, and reduce transmission by detecting C. diff. colonization in patients with diarrhea from other causes.

However, because the tests are very sensitive and can lead to over diagnosis, when there are no pre-agreed institutional criteria that limit testing to patients with significant unexplained diarrhea, the guidelines recommend that a C. diff. common antigen test and a stool toxin test be used as part of a two- or three-step test process.

Not everyone diagnosed with C. diff. requires treatment, McDonald said.

"We often find people get better on their own if they stop taking the offending antibiotic," he said.

Other new treatment recommendations include:

Vancomycin or fidaxomicin – Antibiotics vancomycin or fidaxomicin should be used for initial treatment of even mild C. diff., rather than metronidazole, which the previous guidelines recommended as first-line therapy. Research shows the cure rates are higher for vancomycin and fidaxomicin than for metronidazole.
Fecal microbiota transplantation – The guidelines recommend FMT for patients with two or more recurrences of C. diff. and for whom traditional antibiotic treatment has not worked. FMT is a new treatment since the last guidelines were published but is not approved by the Food and Drug Administration. However, FDA has issued Guidance for Industry.

The guidelines include the same suggestions for preventing the spread of C. diff. as the 2010 guidelines, including isolating infected patients and ensuring healthcare workers and visitors use gloves and gowns.

However, there is also a call for increased attention to antibiotic stewardship to reduce the unwarranted use. While nearly all antibiotics predispose people to C. diff., some are of particular concern, including the fluoroquinolones, cephalosporins and clindamycin.

The guidelines make no recommendations on probiotics.

"We tell patients that for the most part they won’t hurt, but at this point we can't make a recommendation for which ones to use and specifically how to use them," McDonald said.

The new guidelines also include recommendations for epidemiologic surveillance, diagnosis, and treatment of C. diff. in children, which the 2010 guidelines did not address.