Probiotics for C. difficile Infection in Patients on Fidaxomicin
Probiotics are not recommended for patients with active C. difficile infection who are being treated with Fidaxomicin (Dificid). 1
Evidence-Based Rationale
The American Gastroenterological Association (AGA) makes no recommendation for the use of probiotics in the treatment of active C. difficile infection, classifying this as a "knowledge gap" in their clinical practice guidelines 2, 1. The evidence supporting probiotics as adjunctive therapy for active C. difficile infection is insufficient and of low quality.
Current Evidence on Probiotics with C. difficile Treatment
Studies evaluating probiotics as adjunctive treatment for C. difficile infection have shown:
- Heterogeneous study designs and patient populations
- Different probiotic formulations tested
- Inconsistent outcomes
- High risk of bias in most studies 2
While some small studies suggested potential benefits with certain probiotics (like S. boulardii), the overall certainty of evidence is low 2
Some probiotics (like L. rhamnosus ATCC 53103) have actually shown increased recurrence of C. difficile infection compared to placebo 2
Focus on Effective Primary Treatment
Fidaxomicin (Dificid) is already an effective treatment for C. difficile infection with several advantages:
- Non-inferior clinical cure rates compared to vancomycin 3
- Significantly lower rates of C. difficile recurrence (15.4% vs. 25.3% with vancomycin) 3
- Targeted bactericidal activity against C. difficile with minimal effect on normal colonic microflora 4
- This microflora-sparing activity allows for more rapid restoration of the normal colonic microbiota 4
Special Considerations
Immunocompromised Patients
Immunocompromised patients may be at higher risk for complications from probiotic use 2, 1. Since many C. difficile patients are already vulnerable, adding probiotics could potentially introduce additional risk.
Inflammatory Bowel Disease
For patients with inflammatory bowel disease and C. difficile infection, fidaxomicin alone has shown a 60.6% response rate 5. Adding probiotics has not been well-studied in this population.
When Probiotics May Be Considered
While probiotics are not recommended during active C. difficile treatment, the AGA does conditionally recommend specific probiotics for prevention of C. difficile in patients taking antibiotics for reasons other than C. difficile treatment 2, 1:
- Saccharomyces boulardii
- Two-strain combination of L. acidophilus CL1285 and L. casei LBC80R
- Three-strain combination of L. acidophilus, L. delbrueckii subsp. bulgaricus, and B. bifidum
- Four-strain combination of L. acidophilus, L. delbrueckii subsp. bulgaricus, B. bifidum, and S. salivarius subsp. thermophilus
Clinical Algorithm
For patients with C. difficile infection on fidaxomicin:
- Focus on completing the full course of fidaxomicin treatment
- Do not add probiotics as adjunctive therapy
- Ensure adequate fluid intake and supportive care
After completing C. difficile treatment:
- Monitor for recurrence of symptoms
- If recurrence occurs, follow appropriate guidelines for recurrent C. difficile infection
For future antibiotic courses (after C. difficile is resolved):
- Consider one of the recommended probiotic formulations for prevention of recurrent C. difficile infection
Key Pitfalls to Avoid
- Do not rely on probiotics as primary or adjunctive treatment for active C. difficile infection
- Do not assume all probiotics are equivalent - benefits are strain-specific
- Avoid using probiotics in severely immunocompromised patients due to potential risk of complications
- Do not delay appropriate antibiotic therapy while considering probiotic options