Do probiotics help with Clostridioides difficile (C. diff) diarrhea?

Probiotics for C. difficile Diarrhea

Current evidence does not support the use of probiotics for the treatment of active C. difficile infection, as this remains a significant knowledge gap in clinical practice. 1, 2

Prevention vs. Treatment of C. diff

Prevention of C. difficile Infection

For patients receiving antibiotics for reasons other than C. difficile infection, specific probiotics may help prevent C. difficile infection:

• Recommended probiotic strains 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 1, 2

• Effectiveness for prevention:

  • Most beneficial in high-risk populations (>5% baseline risk of C. difficile)
  • Reduces risk by approximately 60% in these high-risk groups 3
  • Number needed to treat: 12 patients in high-risk groups 3

Treatment of Active C. difficile Infection

For active C. difficile infection, standard antibiotic therapy remains the cornerstone of treatment:

• First-line treatments:

  • Vancomycin 125 mg four times daily for 10 days
  • Fidaxomicin 200 mg twice daily for 10 days 2

• Probiotics as adjunctive treatment:

  • The AGA makes no recommendation for probiotics in active C. difficile infection 1, 2
  • Limited evidence from small studies shows mixed results:
    • S. boulardii may have some benefit for diarrhea cessation (RR 1.33) and recurrence reduction (RR 0.59) but with low-quality evidence 1
    • Some strains like L. rhamnosus ATCC 53103 may actually increase recurrence (RR 2.63) 1

Clinical Considerations

Patient Selection

• Probiotics appear most beneficial in patients at high risk for C. difficile (>5% baseline risk) 3
• Caution in immunocompromised patients who may be at higher risk for complications from probiotic use 2

Safety Considerations

• Short-term use of probiotics appears generally safe when used alongside antibiotics in immunocompetent patients 3
• Common adverse events include abdominal cramping, nausea, fever, soft stools, flatulence, and taste disturbance 3

Recurrent C. difficile Infection

• For recurrent C. difficile infection, standard approaches include:
  • Vancomycin using a tapered and pulsed regimen
  • Fidaxomicin for first recurrence
  • Fecal microbiota transplantation (FMT) for multiple recurrences 2

Practical Approach

1. For active C. difficile infection: Use standard antibiotic therapy (vancomycin or fidaxomicin)
2. For prevention in high-risk patients on antibiotics: Consider one of the recommended probiotic formulations
3. For recurrent C. difficile: Follow standard protocols with vancomycin taper, fidaxomicin, or FMT rather than relying on probiotics

Common Pitfalls

• Using probiotics as primary treatment for active C. difficile infection
• Assuming all probiotic strains are equally effective
• Not considering the baseline risk of C. difficile when deciding on probiotic prophylaxis
• Using probiotics in severely immunocompromised patients