What probiotic is recommended for treating Clostridioides difficile (C. diff)?

Probiotics for C. difficile Infection

For treating C. difficile infection, Saccharomyces boulardii is the most supported probiotic option, showing beneficial effects on symptom cessation and reduced recurrence rates, though the evidence quality is low. 1

Evidence for Probiotics in C. difficile Treatment

Current Guideline Recommendations

• The American Gastroenterological Association (AGA) makes no specific recommendations for using probiotics in the treatment of active C. difficile infection due to heterogeneous and limited evidence 1
• The largest study (134 patients) showed that Saccharomyces boulardii may have beneficial effects on:
  • Cessation of diarrhea (RR 1.33,95% CI 1.02-1.74)
  • Reduced recurrence of diarrhea (RR 0.59,95% CI 0.35-0.98) 1
• The World Society of Emergency Surgery (WSES) notes limited direct evidence for probiotics as adjunctive treatment for C. difficile infection 1

Specific Probiotic Options Studied for C. difficile Treatment

1. Saccharomyces boulardii - Most evidence supports this option 1
2. Lactobacillus plantarum 299v - Small trials suggest possible benefits but evidence is very uncertain 1
3. Four-strain combination (L. acidophilus ATCC 700396, L. paracasei ATCC 335, B. animalis lactis ATCC SD5220, B. animalis lactis ATCC SD5219) - Small trials suggest possible benefits but evidence is very uncertain 1
4. Lactobacillus rhamnosus ATCC 53103 - May actually increase recurrence of C. difficile infection (RR 2.63,95% CI 0.35-19.85) and should be avoided 1

Prevention of C. difficile Infection

While not directly addressing treatment, the AGA does recommend certain probiotics for prevention of C. difficile infection in patients taking antibiotics:

• Saccharomyces boulardii (RR 0.41,95% CI 0.22-0.79) 1
• Two-strain combination of L. acidophilus CL1285 and L. casei LBC80R (RR 0.22,95% CI 0.11-0.42) 1
• Three-strain combination of L. acidophilus, L. delbrueckii bulgaricus, and B. bifidum (RR 0.35,95% CI 0.15-0.85) 1
• Four-strain combination of L. acidophilus, L. delbrueckii bulgaricus, B. bifidum, and S. salivarius thermophilus (RR 0.28,95% CI 0.11-0.67) 1

Important Caveats and Considerations

• Primary treatment for C. difficile should always be appropriate antibiotics:

  • Non-severe cases: metronidazole 500 mg three times daily for 10 days 1
  • Severe cases: vancomycin 125 mg four times daily for 10 days 1
  • Current guidelines recommend vancomycin or fidaxomicin as first-line treatments 2

• Probiotics should be considered adjunctive therapy only, not primary treatment

• Safety concerns:

  • Avoid probiotics in severely immunocompromised patients
  • Use caution in patients with severe illness due to potential risks 1
  • Consider cost-benefit ratio for individual patients

• Timing: If using probiotics, they should be administered while on antibiotic therapy for C. difficile, not after completion

Clinical Decision Algorithm

1. Confirm C. difficile diagnosis through appropriate testing (NAAT or GDH followed by toxin A/B detection) 2

2. Initiate appropriate antibiotic therapy based on disease severity:

   • Vancomycin or fidaxomicin for first-line treatment 2
   • Metronidazole only when access to first-line agents is limited

3. Consider adding Saccharomyces boulardii as adjunctive therapy if:

   • Patient is not severely immunocompromised
   • Patient has no contraindications to probiotics
   • Patient is at high risk for recurrence

4. Avoid Lactobacillus rhamnosus ATCC 53103 as it may increase recurrence risk 1

5. For prevention of recurrence in patients requiring future antibiotic courses, consider prophylactic use of Saccharomyces boulardii during antibiotic therapy 1

The overall evidence for probiotics in C. difficile treatment remains limited, with low certainty of evidence across studies. Further research with standardized study designs and larger patient populations is needed to better define which specific probiotics are most effective and which patient populations may benefit most from this intervention.