What probiotics are recommended for a patient with Clostridioides difficile (C. diff) infection?

Probiotics for Clostridioides difficile Infection

For patients with active C. difficile infection, probiotics should only be used in the context of a clinical trial, as there is insufficient evidence to recommend their routine use for treatment of established CDI. 1

Current Evidence on Probiotics for Active CDI

The 2020 American Gastroenterological Association (AGA) clinical practice guidelines specifically address this question and make a clear recommendation:

• The AGA does not recommend any probiotics for patients with active C. difficile infection outside of clinical trials 1
• This is classified as a "knowledge gap" in the guidelines, meaning there is insufficient evidence to make a definitive recommendation for or against probiotic use in this scenario 1

Probiotics for Prevention of CDI

While probiotics are not recommended for treating active CDI, there is evidence supporting their use in specific scenarios:

For Patients on Antibiotics (CDI Prevention)

For patients taking antibiotics for reasons other than CDI treatment, the AGA conditionally recommends specific probiotics to prevent CDI:

• Saccharomyces boulardii 1
• Two-strain combination of Lactobacillus acidophilus CL1285 and L. casei LBC80R 1
• Three-strain combination of L. acidophilus, L. delbrueckii subsp. bulgaricus, and Bifidobacterium bifidum 1
• Four-strain combination of L. acidophilus, L. delbrueckii subsp. bulgaricus, B. bifidum, and Streptococcus salivarius subsp. thermophilus 1

This recommendation is based on low-quality evidence and is conditional, meaning different choices may be appropriate for different patients 1.

Important Considerations

• Probiotics should be administered separately from antibiotics (not simultaneously) to maximize effectiveness 2
• Patients with severe illness or immunocompromised status may be at higher risk for complications from probiotics 1
• Cost considerations may influence the decision to use probiotics 1

Treatment Algorithm for CDI

1. First-line treatment for CDI:

   • Discontinue the inciting antibiotic if possible 1, 3
   • Oral vancomycin 125 mg four times daily for 10 days (first-line for non-severe and severe cases) 1, 3
   • Alternative: Fidaxomicin 200 mg twice daily for 10 days (associated with lower recurrence rates) 1, 3
   • For non-severe cases when vancomycin is unavailable: Metronidazole 500 mg three times daily for 10 days 1, 3

2. For recurrent CDI:

   • First recurrence: Vancomycin or fidaxomicin 1
   • Multiple recurrences: Vancomycin using a tapered and pulsed regimen 1
   • Consider fecal microbiota transplantation (FMT) for multiple recurrences 4, 5

3. Supportive measures:

   • Increase fluid intake 3
   • Consider temporary dietary modifications 3

Pitfalls and Caveats

• Do not rely on probiotics as primary treatment for active CDI - they should not replace appropriate antibiotic therapy 1
• Timing matters - if using probiotics for prevention, they should be administered at a different time than antibiotics to avoid inactivation 2
• Patient selection is crucial - immunocompromised patients may be at higher risk for complications from probiotic use 1
• Strain specificity is important - not all probiotics are equal, and benefits are strain-specific 1
• C. difficile testing should only be performed on diarrheal stool specimens from patients with clinically significant diarrhea (≥3 loose or watery stools in 24 hours) 3

Conclusion

While specific probiotics may help prevent CDI in patients taking antibiotics for other reasons, there is insufficient evidence to recommend probiotics for the treatment of active C. difficile infection. Standard treatment remains appropriate antibiotic therapy with vancomycin, fidaxomicin, or metronidazole based on disease severity and recurrence status.