Introduction: There have been increasing rates of recurrence of C. Diff colitis infection following standard antibiotic treatment in recent years. In antibiotic-refractory patients, fecal microbial transplant (FMT) has become the standard of care. Yet, there remains limited data on real-world practices as well as guidance on optimal timing of the procedure. Regimes outlining the duration of antibiotic course and timing of fecal microbial transplant may guide therapy in patients suffering from persistent C. Diff infection.
Case Description/Methods: A 36-year-old male with a previous medical history of persistent C. Diff presented to clinic for evaluation of diarrheal symptoms intermittently for the last two years, undergoing 12 unsuccessful treatment trials at a nearby clinic. At the current presentation, his serology was again positive for C. Diff; he was initiated on a 14-day course of fidaxomicin along with yogurt and probiotic supplementation. Subsequent serological PCR testing for C. Diff remained positive, consistent with CT abdomen and pelvis findings suspicious for enteritis. His recurrent resistance to standard therapy protocols inspired an unconventional treatment approach: another 14-day course of fidaxomicin, followed by fidaxomicin and cholestyramine for another two weeks, concluded by FMT. Two weeks following this regimen, serology was negative for C. Diff. Follow-up revealed no evidence of recurrence.
Discussion: The rationale behind the proposed approach can be attributed to bacterial and spore growth being the two major components contributing to C. Diff proliferation within the gut. Sufficiently low bacterial and spore loads allow for successful fecal microbial transplants, as the transplanted, healthy colonic gut flora will exist in high enough titers to prevail over the relatively lowered C. Diff bacterial titers. Fecal transplant then restores the normal gut microbiome composition, rendering C. Diff growth incapable of producing clinically significant disease. The aim of this case report is to equip clinicians with meaningful evidence to improve cure rates in treatment-resistant, recurrent C. Diff patients with an exemplary protocol ensuring success due to low bacterial and spore levels prior to fecal transplant.
