Management of Recurrent Clostridium difficile Infection

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.