Can I take probiotics while being treated for Clostridioides difficile (C. diff)?

Probiotics During C. difficile Infection Treatment

Probiotics are not recommended during active C. difficile infection treatment due to limited evidence and potential risks, particularly in immunocompromised patients. 1

Current Guidelines on Probiotics with CDI Treatment

The American Gastroenterological Association (AGA) makes no recommendation for probiotic use during active C. difficile infection treatment, citing a significant "knowledge gap" in the evidence 1. While the World Journal of Emergency Surgery guidelines mention limited direct evidence to support probiotics as adjunctive treatment for a first episode of CDI in immunocompetent patients, they do not make a strong recommendation for their use during active treatment 2.

Key considerations:

• Probiotics should not be administered to patients at risk of bacteremia or fungemia 2
• Immunocompromised patients should not use probiotics due to potential complications 2, 1
• The primary focus should remain on appropriate antibiotic therapy for CDI

Standard Treatment Approach for CDI

The cornerstone of CDI treatment remains appropriate antibiotic therapy:

• First-line treatment options:

  • Vancomycin 125 mg four times daily for 10 days 1
  • Fidaxomicin 200 mg twice daily for 10 days 1
  • Metronidazole 500 mg three times daily for 10 days (only for non-severe cases when vancomycin is unavailable) 1

• For recurrent CDI:

  • First recurrence: Vancomycin 125 mg four times daily for 14 days or fidaxomicin 200 mg twice daily for 10 days 2
  • Multiple recurrences: Vancomycin using a tapered and pulsed regimen 2, 1
  • Consider fecal microbiota transplantation for multiple recurrences that have failed repeated antibiotic courses 1

Probiotics for Prevention vs. Treatment

While evidence is limited for using probiotics during active CDI treatment, there is better evidence for their role in prevention:

• Certain probiotic strains may be considered for prevention in high-risk patients receiving antibiotics, particularly during outbreaks 2, 1
• Specific strains with some preventive evidence include:
  • Saccharomyces boulardii 1
  • Lactobacillus acidophilus CL1285 and L. casei LBC80R combination 1
  • Multi-strain combinations of various Lactobacillus and Bifidobacterium species 1

Important Caveats and Considerations

• Safety concerns: Probiotics may pose risks of bacteremia or fungemia in vulnerable patients 2
• Timing matters: If considering probiotics for prevention, they should be started with antibiotic therapy, not after CDI has already developed 3
• Discontinue inciting antibiotics: If possible, stop the antibiotic that may have triggered the CDI 1
• Supportive care: Ensure adequate fluid intake during CDI treatment 1

Common Pitfalls to Avoid

• Using probiotics in immunocompromised patients, which could lead to serious complications 2, 1
• Relying on probiotics instead of appropriate antibiotic therapy for active CDI
• Continuing the inciting antibiotic unnecessarily, which increases recurrence risk 1
• Using metronidazole for long-term therapy due to potential cumulative neurotoxicity 2

While some research suggests potential benefits of certain probiotic strains against C. difficile 4, 5, 6, 7, current guidelines do not provide strong support for their use during active CDI treatment. The focus should remain on appropriate antibiotic therapy and supportive care.