Management of Recurrent Clostridium difficile Infection

May 9, 2014

Management of Recurrent Clostridium difficile Infection

  1. Neil M. Ampel, MD

Fecal microbiota transplantation was the most cost-effective therapy; use of frozen stool from screened healthy donors was efficacious whether administered by nasogastric tube or colonoscopically.

  1. Neil M. Ampel, MD

Clostridium difficile infection (CDI) recurs in 30% of patients after antimicrobial treatment for a first episode and in 60% of those who have had such treatment for ≥2 episodes. Various strategies exist for managing recurrent CDI, including prolonged courses of oral vancomycin, treatment with oral fidaxomicin, and fecal microbiota transplantation (FMT). FMT has been shown to be effective, presumably by restoring normal gut flora. However, aesthetic barriers, questions about the route of FMT administration, and issues regarding recruitment and screening of stool donors have restricted the use of this method. Now, two research groups have examined the latter two issues.

Konijeti and colleagues performed a decision analysis of the cost-effectiveness of four competing strategies (metronidazole, vancomycin, fidaxomicin, and FMT) for recurrent CDI. FMT delivered by colonoscopy was used as the base-case strategy, but duodenal infusion and enema were also examined. Five treatment scenarios were analyzed; the primary outcome was the incremental cost-effectiveness ratio. FMT by colonoscopy was found to be most cost-effective. In clinical settings where FMT is not available, the most cost-effective strategy would be initial treatment with vancomycin.

In an open-label, randomized, controlled trial involving 20 patients with relapsing or recurrent CDI, Youngster and colleagues compared nasogastric tube (NGT) and colonoscopic administration of frozen stool suspensions from unrelated donors who had been screened for pathogens. Overall, 14 participants (70%) were cured with the first infusion. Of five who were treated a second time, four were cured with no relapses within the 8-week follow-up period. Outcomes were similar between NGT and colonoscopic administration.


Findings from these two studies make a strong case for the use of fecal microbiota transplantation as the initial therapy for recurrent Clostridium difficile infection. Currently, FMT use is limited, partly because of the logistics and expense of recruiting and screening donors. If frozen stool samples from screened donors were widely available, the use of FMT as a treatment modality could well expand.

Editor Disclosures at Time of Publication

  • Disclosures for Neil M. Ampel, MD at time of publication Editorial boards Medical Mycology Leadership positions in professional societies Coccidiodomycosis Study Group (President-Elect)


Reader Comments (2)

Sergeant, Michael, MD, FHM, DAAFP Physician, Hospital Medicine, Locums

It would seem we have the technology to encapsulate appropriately screened screened stool such that it could be delivered orally to be active after passage through the stomach and thus have a product that would be easy to administer absent any procedure at all.

Michael Gaspari, MD Physician, Gastroenterology, Carolina Digestive Health Associates

The results of this small trial of treating relapsing CDI using frozen stool suspensions from unrelated donors is encouraging. Aesthetic considerations aside, it may make FMT available to patients who would otherwise not be candidates for lack of a donor. Whether the method of delivery influences the outcome, at least following the first treatment, remains a question for a larger study. One can only hope that the cost effectiveness of FMT will not be eliminated when a commercialized, standardized product is developed for this purpose, which would seem to be the logical extrapolation of this approach.

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