What is the best probiotic to take after treatment for Clostridioides difficile (C. difficile)?

Best Probiotics After C. difficile Treatment

Currently, there is no specific probiotic that has demonstrated significant and reproducible efficacy in controlled clinical trials for prevention of C. difficile recurrence after treatment. 1

Current Evidence on Probiotics for C. difficile

The 2017 IDSA/SHEA guidelines clearly state that while several probiotics including Saccharomyces boulardii and Lactobacillus species have shown promise for prevention of CDI recurrence, none has demonstrated significant and reproducible efficacy in controlled clinical trials 1. This position is supported by the American Gastroenterological Association, which makes no recommendation for the use of probiotics in the treatment of active C. difficile infection, classifying this as a "knowledge gap" 2.

Specific Probiotics Studied:

• Saccharomyces boulardii: Has shown some promise but lacks conclusive evidence 1
• Lactobacillus species: Some studies suggest potential benefit but results are inconsistent 1
• L. rhamnosus ATCC 53103: May actually increase recurrence of C. difficile infection in some cases 2

Recommended Treatment Approach for C. difficile

Instead of focusing on probiotics, the evidence supports these approaches for preventing C. difficile recurrence:

First-line Treatment Options:

• Vancomycin: 125 mg four times daily for 10 days 1
• Fidaxomicin: 200 mg twice daily for 10 days (associated with lower recurrence rates) 1

For First Recurrence:

• Vancomycin (particularly if metronidazole was used for first episode) 1
• Fidaxomicin: Has been shown to be associated with a lower likelihood of CDI recurrence after a first recurrence 1

For Multiple Recurrences:

• Vancomycin using a tapered and pulsed regimen: After standard dosage of 125 mg 4 times per day for 10-14 days, followed by 125 mg twice daily for a week, then 125 mg once daily for a week, then 125 mg every 2-3 days for 2-8 weeks 1
• Fecal microbiota transplantation (FMT): Should be considered for patients with multiple recurrences who have failed repeated courses of antibiotics 1, 3

Risk Factors for C. difficile Recurrence

Important factors that increase risk of recurrence:

• Administration of other antibiotics during or after initial treatment 1
• Defective immune response against C. difficile toxins 1
• Advanced age 1
• Severe underlying disease 1
• Continued use of proton pump inhibitors (PPIs) 1

Important Considerations and Caveats

1. Discontinue the inciting antibiotic if possible to reduce risk of recurrence 2

2. Avoid metronidazole for recurrent CDI as initial and sustained response rates are lower than for vancomycin, and there's potential for cumulative neurotoxicity 1

3. Consider bezlotoxumab (monoclonal antibody against C. difficile toxin B) as an adjunctive therapy for patients with multiple risk factors for recurrence 3

4. If probiotics are considered (despite limited evidence):

   • Avoid in immunocompromised or critically ill patients due to risk of bacteremia or fungemia 1, 2
   • Select specific strains with some evidence of potential benefit rather than random products 2

5. Microbiota restoration approaches like FMT have shown better evidence for efficacy in recurrent CDI than probiotics 1, 3, 4

The focus of post-treatment management should be on antibiotic stewardship, discontinuation of unnecessary medications that increase risk (like PPIs), and using appropriate antibiotic regimens rather than relying on probiotics that currently lack strong supporting evidence.