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Treating and preventing C. diff infections

Treatment Options

These are some options but each person’s case is different. Please talk to your healthcare team about your specific situation.

Antibiotics
Microbiome Therapeutics
Clinical Trials
Other Options
Surgical Therapy
Prevention
Clinical Practice Guidelines
Other Important Info

ANTIBIOTICS

Currently, the antibiotic options for treating C. diff infections are limited, but center around the following two: fidaxomicin (brand name DIFICID®) or vancomycin.

Your doctor’s decision of which antibiotic to prescribe depends on your medical circumstances, as well as the availability and expense of the treatment. If one antibiotic doesn’t work for you, you may have to try a different one. For an initial mild-to-moderate episode, the recommended treatment is vancomycin 125 milligrams (mg) four times per day or fidaxomicin 200 mg twice per day for ten days.
Antibiotics specifically for refractory or recurrent C. diff (persistent, repeated infections) are often prescribed with a ‘taper’ or ‘pulse’ method of dosing. Tapers are a schedule of prescription that gradually decreases the dose over time, while pulses are doses that are taken over a short period of time, usually repetitively.

Fidaxomicin costs more but has been shown to be just as effective as vancomycin and might be preferable to vancomycin in some cases. If your doctor recommends taking fidaxomicin but cost presents a barrier to you, Merck & Co. (manufacturer of DIFICID®) offers a patient assistance program to offset the financial burden of the treatment.

Vancomycin is a more common choice of treatment for C. diff for a number of reasons, including cost and insurance coverage, the availability of a generic option, and a longer history of use (meaning more clinical research has been done) for C. diff treatment.

In rare cases, metronidazole is used off-label (meaning it has not specifically been approved by FDA for treating C. diff but has demonstrated enough viability for it to be prescribed) but was recently subject to a change in recommendations. A 2021 update to the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) joint guidelines for C. diff infections stated that metronidazole is likely inferior to vancomycin and fidaxomicin, but may be used when other treatments fail or are not available.

MICROBIOME THERAPEUTICS

Doctor and nurse speaking to a patient in recovery room.

Another type of therapy for C. diff is microbiome restoration, which may be prescribed to help prevent recurrence (getting sick with C. diff again) after antibiotics have already been used to fight your infection. There are three main options available: fecal microbiota transplant, REBYOTA™, and Vowst™.

Fecal transplants involve the insertion of donor stool tested for safety, strained, and mixed with a sterile salt solution, into a patient, typically via colonoscopy (the most common method), enema, nasogastric (NG) tube, or oral capsule. Some patients may need additional FMT if the first procedure does not resolve the infection. Close follow-up by your doctor is also recommended to assess your response to the FMT. Some patients may have difficulty finding a provider to administer an FMT or getting the procedure covered by their insurance provider.

REBYOTA™ was approved in December of 2022 by the FDA to prevent C. diff recurrence. It is a liquid mix of live microbes sourced from the stool of donors, also tested for safety, and is administered via enema in an outpatient setting. REBYOTA™ does not require bowel preparation. If you need help paying for REBYOTA™, you may be eligible for a patient assistance program.

Vowst™ is also a microbiota-based product, approved in April of 2023 by FDA for the prevention of recurrence, that is taken orally in capsule form. Patients must complete bowel preparation prior to taking their first dose of Vowst™. There is also a patient assistance program available to reduce the cost of Vowst™ for patients, and a support program to help you or your doctor get more information about the therapy.

It may take some time for these newer therapies to be added to clinical practice guidelines for C. diff. It will be up to you and your healthcare provider to determine if microbiome restoration is for you. These new treatments, unlike FMT, are also not yet approved for use in those under the age of 18. If antibiotic treatments have not resolved your infection, talk to your doctor and together, and you can decide which option may be best for you.

CLINICAL TRIALS

Clinical trials for C. diff treatments remain sparse in many areas. Participation in clinical trials remains an option for patients who fit the criteria of the study population—this can help contribute to research and offer better outcomes for future C. diff sufferers, as well as offset costs for patients and families who may not be able to afford typical treatments. Our Clinical Trials page has a more descriptive list of the options mentioned below.

There are also clinical trials available for patients in the United States and abroad. Below are some of the new drugs in development, but check out our In Your State page for a list of trial centers in your area—including open-label studies (those without placebo groups, or with placebo groups who are aware they are being given placebo treatments) for therapies that are already on the market.

NARROW-SPECTRUM ANTIBIOTICS

MICROBIOME RESTORATION THERAPY

  • VE303 (Phase 3 not yet active)

OTHER TREATMENT OPTIONS

INTRAVENOUS IMMUNOGLOBULIN (IVIG)

Intravenous immunoglobulin, or IVIG, is a pooling of antibodies taken from the plasma of healthy donors to help patients with immunodeficiencies. It has also been used to treat some cases of C. diff (along with other infections and inflammatory conditions). This treatment has many side effects and may not be beneficial to adults, though there is some evidence that it is effective in children.

MONOCLONAL ANTIBODIES

Monoclonal antibodies are proteins made in laboratories that act like the human antibodies from which they were copied. Bezlotoxumab is a monoclonal antibody drug that has been used, alongside antibiotics, to treat C. diff for a number of years. IDSA/SHEA recommend using bezlotoxumab as a co-intervention for patients with a recurrent episode of C. diff in the last 6 months, and mention potential benefits for those with an initial episode who are at high risk for recurrence. There are increased risks for serious side effects in patients with a history of congestive heart failure.

SURGICAL THERAPY

For severe cases of fulminant C. diff, surgical interventions may be necessary. While uncommon, it’s important to know what kind of procedures are done should you or your loved one reach the point of needing surgery.

HOW OFTEN IS IT NEEDED?

Surgery is only needed in 1% of persons with C. diff.

WHAT SHOULD BE DONE?

The best course of action will differ widely depending on a patient’s ability to tolerate surgery and other clinical conditions. Still, options may include a “total colectomy” (complete removal of the large intestine) or “diverting loop ileostomy with colonic lavage and intraluminal vancomycin” (preserves the colon).

WHAT ARE THE RISKS?

Like any surgery, these procedures present risk for complication and post-op mortality. Surgery is usually the last resort, when patients are very sick from C. diff and in the intensive care unit.

PREVENTING C. DIFF INFECTIONS

While the last few years have shown a decrease in hospital-acquired C. diff infections, there has been a steady increase in community-acquired and pediatric infections. It’s important to know your risk factors, practice good hygiene, and avoid taking unnecessary antimicrobials (antibiotics, antivirals, or antifungals) to prevent CDI.

KNOW YOUR RISK FACTORS

The following are the greatest risk factors for contracting CDI:

  • Recent antibiotic use
  • Aged 65 and older
  • Recent stay in a hospital or nursing home
  • Weakened immune systems (for example, people who take immunosuppressants or have cancer or autoimmune conditions like HIV)

EAT HEALTHY

Well-balanced diets high in fiber can also help reduce risk of C. diff infections by cultivating a healthy environment in the gut. Read our Lifestyle & Nutrition Guide for more information on maintaining a good diet before, during, and after C. diff infections.

PRACTICE GOOD HYGIENE

Wash your hands with soap and water every time you use the bathroom and before you eat, both at home and in healthcare settings. Hand sanitizer is not an effective method of killing C. diff spores (the dormant form of bacteria living outside the gut).

DON’T TAKE UNNECESSARY ANTIBIOTICS, ANTIVIRALS, OR ANTIFUNGALS

Antimicrobial resistance, or AMR, is a trait that some pathogens (in this case, microorganisms like bacteria, viruses, or fungi) acquire after repeated exposure to antimicrobial treatments. These treatments are used widely in agriculture, sanitation, and the practice of medicine.

While C. diff hasn’t been shown to be resistant to most antibiotics yet, it can still be difficult to eradicate and is strongly related to the overuse of antibiotics in medicine, which also contributes to AMR.

Whenever possible, make sure you’re not taking antibiotics unnecessarily—that is, for viral or fungal infections. Narrow-spectrum antibiotics are also less likely to facilitate a C. diff infection than broad-spectrum ones such as clindamycin or fluoroquinolone antibiotics (e.g., levofloxacin or ciprofloxacin).

Taking antibiotics prophylactically (intended to prevent disease when there is risk for contracting an infection) before, during, or after surgical or dental procedures should also be limited as much as possible. If you have had C. diff and are worried about needing antibiotics, talk to your doctor about taking specific antibiotics to prevent C. diff from returning. Your doctor may be able to choose antibiotics that are just as effective but pose less risk for C. diff.

CLINICAL PRACTICE GUIDELINES

In June of 2021, both IDSA and SHEA and the American College of Gastroenterology (ACG) released updated guidelines for the management of C. diff infections in adults. The following web links give a brief summary of their recommendations.

Guidelines like these are how doctors receive the most up-to-date, concentrated information about the standards of care for specific illnesses. These guidelines take into account the current state of research on prevention, diagnosis, and treatment of the disease, including both the quality and quantity of data in their decisions on which practices are most desirable.

Having access to these guidelines as a patient or caregiver can be helpful when your healthcare provider is not well-versed in caring for a disease like CDI. While we strive for a world where all providers are educated on the many nuances of C. diff prevention and care, advocating for yourself or your loved one at the doctor’s office to receive the highest quality treatment is still sometimes necessary.

There are also some specific guidelines available for patients with other underlying conditions, such as inflammatory bowel disease (IBD). Follow the links below if you need help finding guidelines that more closely represent your or your loved one’s medical history.

OTHER IMPORTANT INFORMATION

Woman with healthcare provider in procedure room.

DON’T TAKE ANTIMOTILITY DRUGS TO STOP DIARRHEA

It may be tempting to take something like Immodium to put a stop to C. diff diarrhea, but such antimotility drugs can actually do more harm than good.

IDSA and SHEA caution against the use of antimotility agents because of a history of bad outcomes when prescribed without consideration of CDI-specific treatment, and limited data on their use adjunctively with antibiotics.

ACG also recommends against the use of these drugs for the same reasons, citing the possibility of complications or fatality when administered alone without appropriate antibiotics, and no decrease in the duration of symptoms even when administered alongside antibiotics like vancomycin or metronidazole.

STOP TAKING ANTI-ACID DRUGS

While IDSA and SHEA have reported that there is insufficient evidence to suggest discontinuing use of proton-pump inhibitors, powerful anti-acids usually taken for heartburn, for the prevention of CDI, ACG does recommend the discontinuation of these therapies in CDI patients. See here a list of commonly used GERD drugs, and talk to your doctor if you take an antisecretory drug and have, or are at risk for, CDI.

STOP TAKING ANY OTHER ANTIBIOTICS

IDSA and SHEA recommend the discontinuation of the antibiotics which may have caused a patient’s C. diff infection.

Because C. diff infection (CDI) is frequently seen in individuals taking antibiotic medications to treat other infections, it is important to stop taking all antibiotics other than those prescribed by the doctor to treat CDI (the doctor will explain which antibiotics to take and which to stop). This is because taking other antibiotics simultaneously as those used to treat CDI can reduce the effectiveness of the antibiotics used for CDI.

COMMON COMORBIDITIES THAT MAY POSE AN ISSUE: IBD AND PREGNANCY

Pregnancy often comes with more frequent visits to healthcare facilities, use of antibiotics, and other conditions that can increase a person’s risk of contracting CDI—and rates of CDI in people who are pregnant have increased over the past 20 years. C. diff can pose significant risk to a pregnant patient, so talk to your healthcare provider if you’re pregnant and experiencing symptoms of CDI.

If you have an inflammatory bowel disease (Crohn’s disease or ulcerative colitis), you may also be at increased risk for developing CDI or having worse outcomes from the infection.

There are some specific clinical guidelines available for patients with other conditions like those who are pregnant or have an IBD. Follow the links below if you need help finding guidelines that more closely represent your or your loved one’s medical history.

PROBIOTICS: A MIXED BAG

IDSA and SHEA, as of their 2017 guidelines update, do not recommend use of probiotics to prevent C. diff due to insufficient data. No mention of probiotics was included in their 2021 focused update.

ACG explicitly recommends against the use of probiotics for the prevention of CDI in patients being treated with antibiotics, as well as for the prevention of recurrence. The reasoning for this recommendation is the low quality of evidence to demonstrate the benefits of probiotics, suboptimal quality control for the manufacture of probiotics, and the limitations of FDA oversight on probiotics due to their dietary supplement classification. ACG also advises caution against probiotics’ use in immunocompromised patients and those with structural heart disease or central venous catheters, and states that their use may impede the healthy recolonization of the gut microbiome following antibiotic courses.

Many patients informally report success in preventing recurrence by using probiotics (specifically probiotics containing the yeast Saccharomyces boulardii), but it’s important to note that these probiotics may not work for everyone—especially with the possibility of adverse effects as stated by ACG. The gut microbiome is an incredibly complex ecosystem and different in each individual’s body, so only you and your healthcare provider can decide if probiotics are a good choice for you.

FULMINANT C. DIFF

According to IDSA/SHEA’s guidelines, the definition of fulminant CDI includes hypotension (low blood pressure) or shock, ileus, and megacolon (an abnormally enlarged colon). ACG states that this definition, while “less-than-perfect,” is the simplest and most likely to be applied broadly, and thus mirrors the recommendation.

Please note that while PLF is sponsored by many of the manufacturers or facilitators of C. diff therapies, the mention of any drugs on our website is purely for educational purposes. This site is reviewed for medical accuracy by our impartial Scientific Advisory Council and does not indicate preferential treatment for our financial supporters.