Treating Complicated C. difficile Infections
Between the late 1990s and early 2000s, the incidence of Clostridium difficile more than doubled, with 500,000 cases reported in the United States in 2010, resulting in approximately 15,000 deaths. The increase in morbidity and mortality is partly due to the emergence of a new hypervirulent strain of C. difficile.
The current rate of recurrence for C. difficile is high. Between 15 and 30 percent of patients will have a recurrence after the first infection, and 40 to 60 percent of patients with one recurrence will experience a subesequent infection. “A lot of patients who have C. difficile — especially recurring disease — are over age 65,” says gastroenterologist R. Ann Hays, MD.
For patients with recurrent C. difficile infections, UVA Health System is one of the region’s few providers offering an alternative treatment: Fecal Microbiota Transplantation (FMT). During this procedure, processed stool from a noninfected donor is placed in the colon of the infected patient via colonoscopy. The healthy, balanced bacteria from the donor’s stool restore the natural intestinal flora disrupted by antibiotic use and suppress C. difficile growth.
Ninety percent of C. difficile patients do not recur after FMT treatment. “We, along with other centers, find that most people feel better within two to five days,” says Hays.
Hays is part of a multidisciplinary team, which also includes a geriatrician, infectious disease expert and microbiologist. “Drs. [Cirle] Warren, [Laurie] Archbald-Pannone and [Glynis] Kolling have been studying C. difficile for many years,” says Hays.
Indications for FMT
Recent American College of Gastroenterology guidelines recommend that patients be considered for FMT after three laboratory-documented cases of C. difficile. Prior to FMT, a thorough evaluation is done to rule out all other causes of diarrhea. “We want to be wise in the use of this modality since there is the potential for unknown infections, as well as other complications from doing fecal transplant,” says Hays. “We don’t know about long-term effects yet because it is so relatively new.”
The procedure involves a colonoscopy, making use of adaptations to the colonoscope that allow for the insertion of donated stool. The donor’s stool is first diluted with saline, homogenized and filtered to remove debris. The bacteria-containing liquid left behind is placed in syringes and inserted in the patient’s right colon, the “bioreactor of the colon.”
In an effort to reduce the risk for recurrence, prior to the procedure, the patient is encouraged to follow good hand washing precautions and complete an “extreme cleaning” of the home environment with 10 percent bleach solution to destroy any C. difficile spores present. A diet high in plant-based foods is also encouraged before and after the FMT because it supports a diverse population of colonic bacteria.
Patients choose whether to accept stool from an anonymous donor or someone they know. Donors must be healthy adults between the ages of 18 and 65 who are eligible to give blood and have no evidence of infectious disease. They undergo extensive screening, including a health questionnaire, blood work and stool studies to rule out infectious or medical risks.
Complicated C. difficile Clinic
The Complicated C. difficile Clinic is staffed by an interdisciplinary team including:
• R. Ann Hays, MD (Gastroenterology)
• Cirle Warren, MD (Infectious Diseases)
• Sheila Vance, PA-C(Gastroenterology)
To refer a patient, please call the clinic at 434.243.6820 or 434.982.1700.