Tackling C. diff

We can do better

Clostidioides difficile causes diarrhea that can be severe, and can lead to toxic megacolon, sepsis and death.  It occurs in about 58 per 100,00 hospital admissions in the healthcare setting and an additional 63 per 100,000 persons in the community according to the CDC (https://pubmed.ncbi.nlm.nih.gov/36882700). The same article notes mortality rates from 6-11% among hospitalized patients. C.diff remains a high priority pathogen according to both the CDC and WHO.

Disclaimer – I don’t pretend to be an expert on this disease.  But with my appointment to the board of directors of the Peggy Lillis Foundation. (https://cdiff.org), I have had to immerse myself in C. diff epidemiology, prevention, treatment and policy issues. I am sharing in this blog the results of my own (still incomplete) learning process.

While we have made some progress in our battle against C. diff with hospital rates falling in the last decade, this has been accompanied by an increase in community-associated cases and by an increase in recurrence rates. Recurrences are especially morbid and are associated with significant negative personal, familial and societal consequences. 

What can we do to decrease this burden? We have to battle on all fronts including better prevention and more efficacious treatment that avoids recurrence as much as possible. And we have to take the fight to the community as well as the hospital.

To summarize my thoughts –

1.        Provide better access to more efficacious treatment that prevents recurrence by improving insurance coverage and through physician and patient education.

2.        Provide the option for use of (and access to) a live biotherapeutic or fecal microbial transplant for first recurrences at least for some patients.

3.        Implement a requirement for antimicrobial stewardship and infection prevention protocols in long-term care facilities.

4. Improve both patient and physician education regarding C. diff treatment.

A number of C. diff treatment guidelines have been released recently (https://www.idsociety.org/practice-guideline/clostridioides-difficile-2021-focused-update/,https://pubmed.ncbi.nlm.nih.gov/34678515/#:~:text=Recommendations%3A%20Important%20changes%20compared%20with,of%20CDI%20when%20available%20and,https://pubmed.ncbi.nlm.nih.gov/34003176/). While there are some disagreements, the consensus is that primary treatment with fidoxamicin can prevent recurrence compared to less expensive therapies such as oral vancomycin. A major problem is that not all patients have access to this recommended therapy. In some healthcare settings the drug is not on formulary because of its increased cost. Some insurance providers do not cover fidoxamicin.  Clearly, this needs to change.  

Another possible problem is a lack of up-to-date training and education for physicians, especially those in primary care. In many areas of the US (and the world) access to experienced specialists is lacking. This will be more difficult to address.

What should happen if the patient has a recurrence of disease? Here the guidelines differ to a certain extent. With the first recurrence, some suggest sticking with the original treatment in spite of the fact that this did not prevent the recurrence. Others suggest fidoxamicin whether or not this was the first treatment or not. Another option is a vancomycin pulse and taper regimen. For patients at high risk of serious disease, many suggest treatment with a live biotherapeutic (FDA approved and now marketed in enema or oral capsule form) or fecal microbial transplant at the first recurrence.  These therapies are highly efficacious but are more costly. Since neither of these will work in the absence of antibiotic therapy, they would follow antibiotic treatment. On the second recurrence the consensus is to include a live biotherapeutic or fecal microbial transplant in the treatment regimen. One might question why we are withholding these very efficacious therapies until the second recurrence. Is this based on a perception of cost-benefit? (I think we need to carry out a deep dive on cost-benefit of treatment of C. diff recurrence).

Hospitals have been able to reduce C diff infection rates by implementing antimicrobial stewardship protocols, isolation and barrier precautions for infected patients or those suspected to be infected, and intense environmental cleaning regimes for the environment around infected patients. Since many cases are now occurring outside of the hospital setting, we should be focusing on a similar approach in the long-term care setting. In the US, Medicare requires skilled nursing facilities to have an antimicrobial stewardship team similar to that required for acute care hospitals. But for nursing homes and other long-term care facilities there are guidelines but no requirements as yet. This is something that we could change.

C. diff diarrhea is a serious disease that has made its way out of hospitals and into our communities.  We need to change the way we prevent and treat this disease. Doing so will reduce the burden of shattered lives, ongoing suffering and deaths.