What is C.diff?

C.difficile, also called C.diff or CDI (Clostridium difficile infection), is a bacterial infection of the intestinal tract.  The infection causes watery diarrhea and cramping. The effects can range from mild to life-threatening.  Even in its mild form, C.diff causes inflammation of the lining of the colon and irritation or damage to nerve endings.  This inflammatory state may cause bloody stools that also contain mucus.

What Are the Dangers?

As with any diarrhea, there is a risk of dehydration.  Severe cases of C.diff can cause diarrhea 10 or more times a day.  Also, the inflammation of the colon can lead to anemia, swelling of the intestines, ulceration of the intestines, sepsis and kidney failure.  Loss of appetite and loss of fluids could lead to rapid weight loss and heart rhythm problems.

What Causes C.difficile?

While the C. diff bacteria and its spores are found throughout the environment, most people do not acquire an infection from exposure.  People who have recently taken antibiotics or PPI’s are at highest risk of acquiring a C.diff infection.  These two medications have a detrimental affect on two different systems in our intestines that keep them healthy

How Do These Two Medications Lead to C.diff Infection?

Proton Pump Inhibitors, also called PPI’s (such as Prilosec, Prevacid or Omeprazole), lower stomach acid.  Since stomach acid is the first line of defense against the invasion of bacteria into our intestines, having low stomach acid can allow C.diff spores to make it through the stomach unharmed.

We each carry trillions of bacteria in our colon.  When these bacteria are in balance, they act as protectors of our intestinal tract.  Unfortunately, antibiotics do not discriminate between pathogenic bacteria and our beneficial commensal bacteria.  Thus, populations of our beneficial bacteria become depleted after a round of antibiotics and that leaves an opening for C.diff to take root and spread.

The second way that these medications can lead to an infection has to do with bile.  Our biliary system starts with the excretion of bile into our small intestines.  It works like a detergent, picking up fats in our small intestine and cleaning them through the system.  If antibiotics have altered bacterial composition, that alteration can both make changes to the composition of the bile as well as increase bacterial populations that become increasingly tolerant to the cleaning mechanism in bile. C.diff is one of the bacterium that become resistant to the antibacterial nature of bile.  In addition the alteration in the composition of the bile can act as a breeding ground for C.diff spores.  These spores germinate in this unhealthy bile and cause an increase in the C.diff population.

How Do You Treat C.diff?

Ironically, the traditional treatment for C.diff is antibiotics.  Originally, Vancomycin and Flagyl, and more recently, Dificid has been added as an option.  The success rate for these antibiotics vary from 60-90%, with Flagyl being least effective and usually reserved for mild cases.

Dificid has been heralded as the new treatment because it was formulated specifically for C.diff.  It had a 80-90% success rate in a study of 676 patience.  The benefit of Dificid is that it is a narrow spectrum antibiotic that does less damage to the microbiota. It also decreases the production of toxins from C.diff, which can lesson the damage caused by the disease.  It is also a sporicidal, which can help prevent recurrences.  However, 21% of the patients on Dificid had serious adverse response to the antibiotic, including nausea, vomiting, abdominal pain, low white blood cell counts, and intestinal hemorrhage.

Fecal transplants (FMT) are the latest treatment for C.diff.  They have a 80-90% success rate on the first infusion, depending on method used.  If there is a recurrence, FMT has a higher success rating on the second attempt 93-98%.  This makes it stand out from antibiotics which all have significantly lower success rates on the second attempt.  Adverse reactions to FMT have been recorded as bloating, nausea and gas.  Long term follow up show that people who receive FMT for C.diff have a healthier microbiome that has been observed up to 21 weeks after treatment.  This improvement of microbial diversity can prevent future relapse.

Bibliography
Nerandzic, M. M., Pultz, M. J., & Donskey, C. J. (2009). Examination of Potential Mechanisms To Explain the Association between Proton Pump Inhibitors and Clostridium difficile Infection . Antimicrobial Agents and Chemotherapy, 53(10), 4133–4137. http://doi.org/10.1128/AAC.00252-09

Nie, Y., Hu, J., & Yan, X. (2015). Cross-talk between bile acids and intestinal microbiota in host metabolism and health . Journal of Zhejiang University. Science. B, 16(6), 436–446. http://doi.org/10.1631/jzus.B1400327

Morrow, Thomas MD, 2011, Fewer Recurrent Infections of C. difficile Seen With Fidaxomicin, https://www.managedcaremag.com/archives/2011/7/fewer-recurrent-infections-c-difficile-seen-fidaxomicin

Brandt et al., “Long-Term Follow-Up of Colonoscopic Fecal Microbiota Transplant for Recurrent Clostridium Difficile Infection.”

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