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Clostridium Difficile Colitis (cont.)

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How are relapses of Clostridium difficile colitis treated?

Treatment options for relapses of C. difficile colitis include:

  1. A second course of the same or a different antibiotic
  2. Six weeks of treatment with decreasing doses of antibiotics
  3. An oral resin by mouth such as cholestyramine (Questran) that binds toxins and inactivates them
  4. Non-pathogen (harmless) yeast by mouth such as Saccharomyces boulardii, for example, Florastor

Doctors usually treat patients who relapse with another 10 or 14 day course of metronidazole or vancomycin, and a majority of the patients so treated will recover. Nevertheless, some patients will have another relapse.Treatment options for multiple relapses include:

  • Treatment with one of the options listed above that has not already been tried.
  • Vancomycin for six weeks in decreasing doses (125 mg four times a day for one week, three times a day for another week, twice a day for another week and so on), followed by four weeks of cholestyramine (Questran).
  • Two weeks of vancomycin or metronidazole along with four weeks of S. boulardii (Florastor).
  • Fecal microbiota (bacterial population) transplants are becoming more common for relapsing patients because of the great success rates. Feces from non-infected donors are made into a suspension. The source of the transplanted fecal microbiota can be healthy family members, acquaintances or from stool banks. The fecal microbiota may be given by enema or by colonoscopy inserted into the rectum, by a feeding tube inserted through the mouth or nose into the upper small intestine, or by way of frozen capsules taken by mouth. The normal bacteria from the donor's stool displaces the C. difficile bacteria.
  • Passive immunizations with human gammaglobulin has been tried, but has not been demonstrated to be consistently effective. The theory is that patients with multiple relapses typically have low levels of antibodies to C. difficile toxins. By giving patients who relapse gammaglobulin. containing large amounts of antibodies to C. difficile toxins, the patients' levels of antibody to C. difficile toxins are increased. Pooled human gammaglobulin can be administered intravenously. However, this treatment is neither approved nor recommended.
  • Active vaccination for C. difficile toxins. Vaccination can increase a patient's levels of antibodies to C. difficile toxins. This is a new treatment that has not become widely available.

What is new in Clostridium difficile?

The prevalence of C. difficile infection has been increasing steadily particularly in the elderly. There have been reports from several hospitals of a newer, more virulent strain of C. difficile bacteria that produces large amounts of both toxins A and B and as well as a third toxin. This strain produces more severe colitis than the usual strains. Patients infected by this strain are more seriously ill, require surgery more frequently, and die from the infection more frequently than patients infected with the usual strains. Currently, the commercially available diagnostic tests cannot distinguish this strain from the usual strains.

Traditionally, antibiotic use is often considered the most important factor for the development of C. difficile colitis. Increasingly though doctors are diagnosing C. difficile colitis in patients without previous antibiotic exposure. This is especially true in patients with Crohn's disease or ulcerative colitis. In one study of 92 patients with ulcerative colitis and Crohn's disease relapse, 10 patients tested positive for C. difficile.Another change that is occurring with C. difficile infection is that it is no longer restricted to patients in hospitals or nursing homes. A study of data from 2009 through 2011 found community-associated C. difficile infections represent about one third of all C. difficile colitis cases. Traditionally, antibiotic use is often considered the most important factor for the development of C. difficile colitis, but in this study, 36% of the patients had not been treated with antibiotics.

Doctors are witnessing increasing difficulty in treating C. difficile colitis. Firstly, resistance to metronidazole is on the rise. Secondly, colitis (along with symptoms of diarrhea and cramps) is taking longer to resolve and may require higher doses of vancomycin. Thirdly C. difficile colitis relapse (with recurrent diarrhea) is common. More troublesome still, many patients experience multiple relapses, often requiring prolonged (months) antibiotic (such as vancomycin) treatment.

Medically reviewed by Robert Cox, MD; American Board of Internal Medicine with subspecialty in Infectious Disease


"Clostridium difficile in adults: Epidemiology, microbiology, and pathophysiology"

Medically Reviewed by a Doctor on 10/11/2016


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