What probiotic is recommended for a patient with Clostridioides difficile (C. diff) infection?

Probiotics for Patients with C. difficile Infection

No probiotics are currently recommended for the treatment of active Clostridioides difficile infection (CDI), as this is classified as a knowledge gap with insufficient evidence according to the American Gastroenterological Association (AGA). 1

Current Evidence on Probiotics for CDI

The most recent guidelines from both the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) indicate that while several probiotics have shown promise for prevention of CDI recurrence, none has demonstrated significant and reproducible efficacy in controlled clinical trials 1.

Similarly, the AGA makes no recommendation for the use of probiotics in the treatment of active C. difficile infection, explicitly classifying this as a "knowledge gap" 2, 1. The 2020 clinical decision support tool published in Gastroenterology specifically lists "symptomatic treatment of C. difficile infection" under the "no recommendation, knowledge gap" category 2.

Probiotics for Prevention in Antibiotic Users (Not CDI Patients)

It's important to distinguish between:

• Treatment of active CDI (not recommended)
• Prevention of CDI in patients taking antibiotics for other reasons (conditionally recommended)

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

• 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 2, 1

Standard Treatment Approach for CDI

Instead of probiotics, the recommended treatments for CDI include:

1. First-line treatments:

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

2. For recurrent CDI:

   • Vancomycin using a tapered and pulsed regimen
   • Consider fidaxomicin for first recurrence 1

3. For multiple recurrences:

   • Fecal microbiota transplantation (FMT) should be considered for patients who have failed repeated courses of antibiotics 1, 3

Important Considerations and Caveats

• Discontinue the inciting antibiotic if possible, as this is a key factor in CDI management 1
• Immunocompromised patients may be at higher risk for complications from probiotic use 1
• The gut microbiota plays a crucial role in providing colonization resistance to C. difficile, which explains why FMT has shown success rates of 70-90% in severe and fulminant CDI 4, 3
• Metronidazole is now considered inferior to vancomycin and fidaxomicin and should only be used in mild-to-moderate disease in younger patients with few risk factors for recurrence 5

Risk Factors for CDI Recurrence

• Administration of other antibiotics during or after initial treatment
• Advanced age
• Severe underlying disease
• Continued use of proton pump inhibitors (PPIs) 1

In conclusion, while probiotics may have a role in preventing CDI in patients taking antibiotics for other reasons, they are not recommended for the treatment of active CDI based on current guidelines. Standard antibiotic therapy with vancomycin or fidaxomicin remains the cornerstone of treatment.