What are the benefits of colonoscopy in patients colonized with Clostridioides difficile (C. difficile)?

From the Guidelines

Colonoscopy is beneficial for patients colonized with Clostridioides difficile (C. difficile) when used for diagnostic clarification or as a route for fecal microbiota transplantation (FMT) in severe or fulminant CDI, as recommended by the AGA guidelines 1. The primary benefits of colonoscopy in these patients include:

• Diagnostic clarification when other conditions are suspected alongside C. difficile colonization
• Direct visualization of the colonic mucosa and collection of tissue samples to differentiate between asymptomatic C. difficile colonization and active C. difficile infection (CDI)
• Identification of alternative or concurrent diagnoses such as inflammatory bowel disease, microscopic colitis, or colorectal cancer that might be causing symptoms
• Administration of FMT via colonoscopy, which has been shown to be effective in treating recurrent or refractory CDI, with a high success rate and long-term durability 1 However, colonoscopy carries risks in patients with active CDI, including potential perforation of inflamed bowel tissue and possible spread of C. difficile spores within healthcare facilities. For asymptomatic carriers, treatment is not recommended as approximately 3-5% of healthy adults and up to 50% of hospitalized patients may be colonized without symptoms. Colonoscopy should be reserved for cases where diagnostic uncertainty exists or when other colonic pathologies need to be ruled out, and should be performed with appropriate infection control measures, including terminal cleaning of endoscopy equipment and rooms to prevent transmission to other patients 1. Key considerations for the use of colonoscopy in patients with C. difficile colonization include:
• The AGA guidelines recommend the use of conventional FMT over no FMT in adults hospitalized with severe or fulminant C. difficile infection not responding to antimicrobial therapy 1
• FMT should be considered in hospitalized patients not responding to standard of care antibiotics, generally within 2–5 days after initiating CDI treatment 1
• Colonoscopy allows the provider to confirm the diagnosis and determine CDI severity, and is a recommended route for FMT administration in severe or fulminant CDI 1

From the Research

Benefits of Colonoscopy in Patients Colonized with C. difficile

• The use of colonoscopy for faecal microbiota transplantation (FMT) has been shown to be an effective treatment for recurrent C. difficile infection, with a resolution rate of 90% in one study 2.
• FMT via colonoscopy has been compared to vancomycin treatment, with results showing that FMT is significantly more effective in resolving C. difficile-associated diarrhea 2.
• In patients with severe refractory C. difficile infection, a pseudomembrane-driven FMT protocol consisting of multiple faecal infusions and concomitant vancomycin has been shown to be more effective than a single faecal transplant followed by vancomycin 3.
• Colonoscopy can also be used to deliver donor faeces, which has the potential to optimize treatment strategies in patients with pseudomembranous colitis 2.
• The use of FMT via colonoscopy has been recommended as a treatment option for patients with multiple recurrent episodes of C. difficile infection who have received appropriate antibiotic therapy 4.

Advantages of Colonoscopy in C. difficile Infection Treatment

• Colonoscopy allows for the direct delivery of faecal microbiota to the colon, which can help to restore the normal gut flora and resolve C. difficile infection 2, 3.
• The use of colonoscopy for FMT has been shown to be safe and well-tolerated, with no significant adverse events reported in several studies 2, 3.
• Colonoscopy can also be used to visualize the colon and diagnose pseudomembranous colitis, which is a complication of C. difficile infection 5.