Treatment options in Clostridium difficile infection

There is an increased interest in exploring antibacterial, biotherapy and immunological treatment options for Clostridium difficile infection. The impetus has occurred from increased antibiotic use, the rising incidence of C. difficile infection in the elderly and high rates of recurrence associated with metronidazole and vancomycin therapy. However, progress has been hampered by the varied aetiology of diarrhoea, spontaneous and unpredictable symptomatic resolution in some patients and inconsistencies in diagnosis. C. difficile may be treated with vancomycin or metronidazole as the overall response and recurrence rates are not statistically significantly different. However, metronidazole is the antibiotic of first choice as it reduces the selective pressure for glycopeptide-resistant enterococci, promoted by the widespread use of vancomycin. Management of symptomatic recurrences is problematic; switching between vancomycin and metronidazole is not recommended as DNA fingerprinting studies demonstrate that relapses are often re-infections with different strains. Placebo-controlled, double-blind trials on Saccharomyces boulardii given prophylactically to patients receiving antibiotics reported a reduced incidence in antibiotic-associated diarrhoea. Further double-blind, placebo-controlled trials demonstrated that treatment with S. boulardii significantly reduced recurrent C. difficile diarrhoea. Case reports suggested that Lactobacillus GG reduced recurrent C. difficile infection and there is only one partially reported, prospective, randomized, placebo-controlled trial of Lactobacillus GG in adults with C. difficile infection. Prophylactic bovine immunoglobulin prevented diarrhoea in C. difficile-exposed hamsters and two patients with severe colitis unresponsive to antibiotics improved following intravenous immunoglobulin therapy. SYNSORB Cd®, a novel compound, is reported to reduce C. difficile diarrhoeal recurrence rates and is undergoing phase III study.