Review Suggests Several Promising Prophylaxis Treatments for Clostridioides difficile Infection

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In a narrative review, investigators examined available literature on the prevention and treatment of Clostridioides difficile infection (CDI) in adults, examining the differences among American College of Gastroenterology guidelines, Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (IDSA/SHEA) guidelines, and new literature published after the guideline updates.

There are several different options for prophylaxis, which include probiotics and antibiotics, such as fidaxomicin and vancomycin.

There is limited literature supporting fidaxomicin, while more studies have evaluated probiotics and vancomycin, according to investigators.

However, they also noted that the patient population and regimens for the use of probiotics and vancomycin were not determined.

The IDSA/SHEA guidelines did not recommend the use of probiotics, because of insignificant evidence. However, the ACG guidelines recommended against the use for probiotics.

Most trials that led to this conclusion evaluated the incidence of CDI as a secondary endpoint, according to investigators.

However, investigators did notice that there were potential benefits to and recommendations for probiotics, particularly because they have a relatively low risk of adverse events (AEs).

In the review, investigators analyzed studies to determine how well tolerated the probiotics were. They determined that short-term probiotics had no increase in the number of AEs or serious AEs. Additionally, the case studies also showed that individuals who were immunocompromised were most likely to experience probiotic-related AEs.

Probiotics could probably benefit institutions or patients who have a high baseline rate of CDI, according to investigators.

However, they added that more controlled, randomized trials are needed to detect which probiotic strains can be most beneficial.

The IDSA/SHEA guidelines discourages the use of metronidazole for mild CDI episodes, investigators said.

However, the literature reviews, evidence suggests this could still be an option for patients, according to investigators.

Further, they noticed that fidaxomicin is superior to vancomycin in reducing recurrence but cost remains a barrier for prescribing.

Fidaxomicin has a narrower spectrum and decreases the risk of damage to the gut microbiome when compared to vancomycin, according to investigators.

However, recent study results have suggested that fidaxomicin’s cost-effectiveness as a first-line therapy is dependent on institutional contracts and payment structures.

As secondary prophylaxis, the literature focused on non-antimicrobial options, which was aimed at lessening the impact on the gut microbiome, investigators said.

The options for fecal microbiota transplantation, SER109, and RXB2660, which the FDA recently approved, could be new options to combat dysbiosis.

To prevent recurrences, an attractive option would be bezlotoxumab, investigators said.

The non-toxigenic administration of bezlotoxumab could decrease the development of antimicrobial resistance, which is promising for the future of prophylaxis treatment of CDI, investigators said.

Further head-to-head studies of new agents will be needed to help update the guidance of optimal therapies for CDI primary and secondary prophylaxis, they said.

Reference

Bainum TB, Reveles KR, Hall RG II, Cornell K, Alvarez CA. Controversies in the prevention and treatment of Clostridioides difficile infection in adults: a narrative review. Microorganisms. 2023;11(2):387. doi:10.3390/microorganisms11020387