Read the complete Weekly Update/earn CME credit
About a quarter of patients treated for Clostridium difficile infections develop recurrent symptoms after a standard course of antibiotics. Recurrent C. difficile infections can be particularly resistant to further antibiotic treatment, and with each recurrence the risk of another recurrence increases. Probiotics have been tried for treating recurrent C. difficile, but evidence for efficacy is limited and inconsistent (Am J Gastroenterol 2006 Apr;101(4):812, Clin Infect Dis 2000 Oct;31(4):1012). However “stool transplants” of donor feces, an alternative approach to restoring the diversity of intestinal flora, have been reported to result in high rates of resolution in case series (Arch Intern Med 2012 Jan 23;172(2):191, Clin Infect Dis 2003 Mar 1;36(5):580). Evidence from a randomized trial for this treatment had been lacking until now.
In a recent small trial, 43 patients (mean age 68 years) with recurrent C. difficile diarrhea after at least 1 course of antibiotics were randomized to 1 of 3 treatments. The first group had a 4-5 day course of vancomycin followed by bowel lavage and then donor feces infusion through nasoduodenal tube. Feces were diluted in 500 ml of 0.9% saline, stirred, and the supernatant was then administered within 6 hours following collection from donor. All donors were < 60 years old and screened for risk factors associated with potentially transmissible diseases. An additional infusion with feces from a different donor was given if infection recurred. The second group received a 14-day course of vancomycin plus lavage, and the third received vancomycin for 14 days only.
The primary outcome was cure of C. difficile infection within 10 weeks, defined as absence of diarrhea (or persistent diarrhea explained by other cause) plus 3 consecutive stool tests negative for C. difficile. The cure rates were 94% with feces infusion, 23% with vancomycin plus lavage, and 31% with vancomycin only (p < 0.001 for feces infusion vs. each group, NNT 2) (level 2 [mid-level] evidence). Symptoms were resolved in all but 3 patients (81%) in the infusion group after the first treatment. Two additional patients were cured after a second infusion. Diarrhea was common on the day of infusion in that group. The planned enrollment was 120 patients, but the trial was terminated early after an interim analysis showed a significant difference in efficacy (N Engl J Med 2013 Jan 16 early online).
For more information, see the Clostridium difficile infection topic in DynaMed.