http://www.medscape.

com/viewarticle/733426

Alternative Therapies for Clostridium difficile Infections

Abstract and Introduction
Abstract
Clostridium difficile infection is a serious condition responsible for significant morbidity and mortality, especially in patients being treated with antimicrobials. Increasing frequency of the infection and hypervirulent C. difficile strains have resulted in more severe disease as well as therapeutic failures with traditional treatment (metronidazole and vancomycin). To review the studies assessing nontraditional therapies for the prevention and treatment of primary or recurrent C. difficileinfection, we conducted a literature search of the PubMedMEDLINE databases (19842010). Of the 98 studies identified, 21 met our inclusion criteria. Five clinical trials and one retrospective medical record review evaluated probiotic or prebiotic formulations for the prevention of C. difficile infection. Only one of these studies, which included Lactobacillus caseiand L. bulgaricus in the probiotic formulation, showed efficacy. Ten clinical trials evaluated treatment of an initial episode of C. difficile infection (primary treatment) with the antimicrobials fidaxomicin, fusidic acid, rifampin, teicoplanin, and nitazoxanide, as well as the toxin-binding polymer, tolevamer. Only nitazoxanide and teicoplanin demonstrated noninferiority when compared with vancomycin or metronidazole. Four prospective studies and one retrospective study evaluated treatment of relapsing C. difficile infection. Prebiotic formulations for the prevention and treatment of recurrent C. difficile infection have not proved to be clinically warranted. Nitazoxanide, teicoplanin, and fidaxomicin may be considered as alternatives to traditional treatment; however, clinical experience is limited with these agents for this indication. Bacteriotherapy with fecal instillation has demonstrated high clinical cure rates in case studies and in a retrospective study; however, to our knowledge, randomized clinical trials are lacking for this therapeutic approach. As C. difficile infection rates continue to increase and hypervirulent strains continue to emerge, it is important for future clinical studies to assess alternative therapies.

Introduction
Clostridium difficile infection is a serious medical condition that typically manifests as profuse diarrhea, abdominal cramping, fever, and leukocytosis. It is responsible for most cases of antibiotic-associated diarrhea and 90100% of cases of antibiotic-associated pseudomembranous colitis.[1, 2] Clostridium difficile is a gram-positive, spore-forming, obligate anaerobe that was first described in 1935 when isolated from the intestinal flora of neonates.[3] Previously thought of as a commensal organism of the human intestinal tract, C. difficile isolation studies have shown that only 13% of healthy adults are carriers of the microbe. However, frequency of carriage increases in individuals exposed to certain environments (e.g., hospitalized patients, long-term care facility residents, employees and caregivers at such institutions). Reported rates of colonization have been as high as 50% for those with hospital stays lasting longer than 4 weeks.[46] The pathogenesis of C. difficile infection begins by disruption of the normal host gut flora, which is most often attributable to broad-spectrum antibiotics, followed by ingestion of C. difficile spores.[7] These precipitating events allow for C. difficile colonization to occur and the possibility of disease to commence. Depending on host immune response, colonization may lead to an asymptomatic carrier status or, if infected with a pathogenic strain, development of severe symptoms due to toxin production. Nonpathogenic strains of C. difficile do not produce toxins, whereas pathogenic strains generate toxins A and B, or toxin B alone.[8, 9] Toxin A, an enterotoxin, and toxin B, a cytotoxin, are the main virulent factors responsible for inflammation and necrosis of the intestinal lining, emanating as colitis and diarrhea.[10, 11]

Traditional Therapies for Clostridium difficileInfection

Standard pharmacologic treatment for C. difficile infection is aimed at achieving adequate bactericidal fecal concentrations. Oral vancomycin and metronidazole are considered the agents of choice, although vancomycin is currently the only United States Food and Drug Administrationapproved therapy for C. difficile infection. According to the most recent treatment guidelines from the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America, the recommended pharmacotherapeutic option is stratified based on disease severity. For mild-to-moderate cases of C. difficileinfection,

metronidazole 500 mg orally 3 times/day for 1014 days is the preferred regimen.[12] Metronidazole has been shown to have a 98% cure rate and is comparable to vancomycin in terms of efficacy.[13, 14] The choice of metronidazole versus vancomycin may stem from pharmacoeconomic considerations, as the cost of metronidazole is far less than vancomycin ($0.70 for each 500-mg metronidazole tablet vs $17.70 for each 125-mg vancomycin capsule).[15, 16] Also important to consider is that the presence of vancomycin-resistant enterococci is associated with overuse of the oral formulation of vancomycin, although some data suggest that metronidazole may contribute to the presence of vancomycinresistant enterococci as well.[1719] In severe cases of C. difficile infection, oral vancomycin 125 mg 4 times/day for 1014 days is recommended. In complicated cases, oral vancomycin 500 mg 4 times/day with or without intravenous metronidazole 500 mg every 8 hours is recommended. If treating a recurrent case of C. difficile infection for the first time, it is acceptable to use the same regimen that was used for the initial episode, as long as disease severity is taken into account. However, treatment beyond the first recurrence should be with a tapered and/or pulsed-dosed regimen of vancomycin. Patients should not be rechallenged with metronidazole due to potential cumulative neurotoxic effects.[12] The overall incidence and severity of C. difficile infection have been increasing in North America and abroad.[2022] Since early 2000, there have been increasing outbreaks of a more virulent C. difficilestrain, classified as North American PFGE type 1 and PCR-ribotype 027 (NAP1/027). This hypervirulent strain has demonstrated greater spore-forming capabilities, increased toxin production, and higher failure rates with metronidazole therapy compared with other strains. [23 25] Also troubling are reports of high recurrence rates of the infection, which suggests reinfection with a different strain or relapse involving the same strain leading to treatment failure.[10, 26] After the first episode of C. difficile infection, up to 30% of patients relapse within 2 months. The risk of relapse is nearly doubled if there is a second occurrence of the infection.[27, 28] For patients whose infection fails to completely resolve and who exhaust all traditional treatment options, newer therapeutic strategies must be evaluated. Various studies, ranging from single case studies to multicenter clinical trials, have investigated nontraditional treatment strategies for C. difficile infection. We reviewed the literature, with a goal of summarizing the strengths and weaknesses of the studies so that further evaluation of these therapeutic strategies could proceed.

Literature Search and Data Collection

We conducted a literature search of the PubMed-MEDLINE databases that comprised a 26-year time span (January 1984March 2010) to identify clinical trials, retrospective studies, and case reports related to prophylaxis and treatment of C. difficileinfection. The search was limited to studies in humans and Englishlanguage articles. Bibliographies of the articles were also reviewed for pertinent studies performed during our specified time frame. Search terms were Clostridium difficile, pseudomembranous colitis, Clostridium toxin, treatment, therapy, prophylaxis, recurrent, relapse, probiotic, prebiotic, toxin-binding, immunoglobulin, nitazoxanide, rifampin, rifaximin, tolevamer, bacteriotherapy, bacitracin, whey protein, teicoplanin, toxoid vaccine, and bovine. For each study included in the review, the following information was collected: study type (e.g., prospective, retrospective, observational, randomized, nonrandomized, placebo-controlled, open-label, case report), location and duration of study, inclusion and exclusion criteria, C. difficile infection diagnosis methods, patients' age range, intervention(s) used, dosage regimen, and end points. Articles were first grouped based on study type: prospective clinical trials, retrospective observational studies, or case reports. Case reports were assessed and included for discussion but were not summarized individually. Each study was further classified according to the target population and the clinical end point(s) as evaluating prophylaxis, primary therapy, or therapy for recurrent C. difficileinfection. Prophylaxis was defined as intervention with a pharmacologic and/or biologic agent to prevent C. difficileinfection in patients with one or more risk factors (hospitalization, resident of long-term care facility, antibiotic exposure, age > 65 yrs, abdominal surgery or gastrointestinal procedure, or a compromised immune system).[29, 30] Primary therapies were treatments used for patients with newly diagnosed C. difficile infection who had not received treatment for this infection before enrollment. Therapies for recurrent disease were interventions used for treating patients with a diagnosis of C. difficile infection who had failed previous treatment or presented again with the infection up to 1 year after initial therapy. Although most recurrences happen 12 weeks after treatment, a 1-year time span from a previous infection was allowed, as individuals with recurring C. difficile infections are typically more difficult to treat.[31, 32] With both primary and recurrent therapies, "cure" was defined within each study as clinical resolution of symptoms, laboratory eradication of evidence of C. difficile infection, or a combination of both.

Ninety-eight studies were identified by using the specified search criteria. After full-text analysis, 19 clinical studies and two retrospective studies were included for final review. The types of articles excluded were review articles, pharmacokinetic and/or safety studies with no efficacy information included, hygienic preventive studies, correspondence, and studies of the traditional pharmacologic approach (metronidazole or vancomycin).

Prospective Clinical Trials on Alternative Therapies for Clostridium difficile Infection

Prophylaxis
Five clinical trials evaluated agents for prophylaxis against C. difficile infection. Four were double-blind, randomized, placebo-controlled studies and included different probiotic formulations; the remaining study tested a prebiotic in a blinded, controlled trial (Table 1).[3337] These trials included various patient populations, and all were conducted in European hospitals. Pediatric patients aged 3 months 14 years and elderly patients older than 50 or 65 years were enrolled in the various trials. The first study was conducted at three different London hospitals and measured the occurrence of diarrhea and C. difficile infection in patients who were prescribed antibiotics.[33]Patients were randomly assigned to receive a probiotic yogurt drink containing Lactobacillus casei, Streptococcus thermophilus, and L. bulgaricus, or a sterile milkshake within 48 hours of starting antibiotic therapy. The study drug was continued 1 week after the discontinuation of the antibiotic therapy. Strict exclusion criteria resulted in a less than 10% enrollment rate, leaving a total of 113 patients for analysis. The average ages of patients in the probiotic and placebo groups were 73.7 and 73.9 years, respectively. Patients younger than 50 years were excluded, as were patients taking high-risk antibiotics (clindamycin, cephalosporins, and aminopenicillins). In the probiotic group, 7 (12%) of 57 patients experienced antibiotic-associated diarrhea, compared with 19 (34%) of 56 patients in the placebo milkshake group (p=0.007). A significant difference also was noted in C. difficiletoxin detection between the two groups in favor of the probiotic group. In another study, which was conducted at two Polish pediatric hospitals, children aged 3 months14 years were randomly assigned to receive a probiotic with L. rhamnosus or placebo (nonfat milk and saccharose) while receiving antibiotic

therapy.[34] No significant differences were noted between the placebo and probiotic groups in the frequencies of antibiotic-associated diarrhea, diarrhea caused by C. difficile, or any other causes of diarrhea including rotavirus, adenovirus, and Salmonella species. In another pediatric study, patients were enrolled from three Polish hospitals. [35] All patients were receiving oral or intravenous antibiotic treatment for otitis media and/or respiratory tract infections. Those included in the trial were randomly assigned to receive a wafer containing Saccharomyces boulardii 250 mg or placebo (made of lactose) twice/day for the duration of antibiotic therapy. The probiotic wafer was found to reduce the risk of antibiotic-associated diarrhea compared with placebo (3.4% vs 17.3%, relative risk 0.2, 95% confidence interval [CI] 0.070.5). A lower risk of C. difficilediarrhea trended in favor of the probiotic group compared with the placebo group; however, this difference failed to reach statistical significance (Table 1). In a pilot study from the United Kingdom, hospitalized patients were randomly assigned to receive a probiotic capsule containing L. acidophilus and Bifidobacterium bifidum or placebo within 36 hours of starting antibiotic treatment.[36] Stool samples from 138 patients receiving antibiotic therapy that lasted no longer than 20 days were analyzed. Of the 138 samples, 20 were found to be positive for C. difficileassociated toxins, 9 (7%) in the placebo arm and 11 (8%) receiving the probiotic. Seven of nine patients in the placebo group were toxin positive, and six of these patients developed diarrhea. Of the 11 patients receiving probiotics who were positive for C. difficile, five were toxin positive, two of whom presented with diarrhea. A 32% difference was found between the detection of toxin among C. difficilepositive patients in the placebo and probiotic groups (95% CI 9.661%). As more C. difficilepositive patients but fewer occurrences of diarrhea were found in the probiotic group versus the placebo group, the authors hypothesized that the probiotics played a role in toxin neutralization rather than prevention of colonization. Overall, the proportion of those developing diarrhea with positive C. difficile toxin assays was lower in the probiotic group than placebo group, but this trend was not statistically significant (Table 1). In another pilot study from the United Kingdom, investigators administered the prebiotic oligofructose to inpatients older than 65 years who had been prescribed a broad-spectrum antibiotic in hopes of reducing the rate of antibiotic-associated diarrhea.[37] Oligofructose was hypothesized to decrease diarrhea caused by C. difficile by promoting the growth of bifidobacteria and decreasing the numbers

ofClostridium species in the gastrointestinal tract. Bifidobacteria have been hypothesized as having a protective quality by inhibiting the growth of pathogenic species and antagonizing the adhesion of pathogenic Clostridium species.[38, 39] Although well tolerated and successful in increasing bifidobacteria fecal concentrations, oligofructose did not reduce the frequency of antibiotic-associated diarrhea and diarrhea caused by C. difficile. Twenty-two (10%) of 215 patients who were prescribed oligofructose developed toxin-positive C. difficile diarrhea, compared with 27 (12%) of 220 patients who received placebo.

Primary Treatment
For treatment of an initial episode of C. difficile infection, 10 prospective, randomized clinical trials were identified and are summarized in Table 2.[40 49] Each trial included a randomized design to compare either comparator agent(s) or different dosages of a single agent. For each study, clinical cure was defined by different criteria; however, all definitions included clinical resolution of diarrhea and gastrointestinal symptoms within a specified time period. Patients were followed for 3060 days to monitor for rates of recurrence. Diagnosis of C. difficile was defined as toxin detection by means of enzyme immunoassay and/or positive cultures for C. difficile. A highly active agent against C. difficile, fidaxomicin, was analyzed in a phase II clinical trial.[40]Fidaxomicin is a bactericidal agent with selective activity against anaerobic gram-positive species but not gram-negative obligate anaerobes. In this study, doses of fidaxomicin ranging from 50200 mg twice/day were given to C. difficile toxinpositive patients. Clinical cure was assessed as the resolution of diarrhea and abdominal discomfort within the 10-day treatment period. Recurrence of C. difficileinfection was monitored for 6 weeks after completion of treatment. The median age of patients was 56 years (range 18 90 yrs). Across all treatment groups, the clinical cure rate was 91%. Of the 41 patients initially considered clinically cured, 2 (5%) experienced a recurrence of C. difficile infection during the 6-week follow-up. Resolution of diarrhea within 10 days was achieved at highest frequency among those receiving the 200-mg twice-daily dose of fidaxomicin. Nitazoxanide is an antiparasitic that is used for treatment of diarrhea caused by Cryptosporidiumspecies, Giardia species, and C. difficile infection. Two thirds of this drug and its metabolite, tizoxanide, penetrate the feces and inhibit C. difficile. [50] Two studies compared the efficacy of nitazoxanide versus standard therapy for C. difficile infection.[41, 42] In a 2006 study, patients with average ages

between the different treatment groups ranging from 66.8 69.2 years were recruited from seven medical centers across the United States.[41] This study demonstrated no significant difference in efficacy between nitazoxanide and metronidazole in the treatment of C. difficile colitis. Differences in clinical response (defined as a return of normal stool pattern and absence of fever, abdominal pain, or leukocytosis) after 7 days of treatment trended toward greater response rates for those who received nitazoxanide (7- or 10-day course) versus metronidazole (89.5% vs 82.4%, difference 7.1%, 95% CI 7.025.5%). A sustained clinical response after 31 days of treatment was not statistically significantly different between patients who received metronidazole and those who received nitazoxanide. Vancomycin versus nitazoxanide was compared in a 2009 study, but noninferiority of nitazoxanide could not be concluded because of the small sample size.[42] As a result of slower than expected patient recruitment, the study was terminated early. No significant differences were noted between the vancomycin and nitazoxanide groups in terms of age (65.7 and 59.6 yrs, respectively, p=0.19), inpatients enrolled (78% and 95%, respectively, p=0.11), or presence of severe C. difficile infection (37% and 45%, respectively, p=0.57). Twenty-seven patients received vancomycin and 23 received nitazoxanide, providing a power of only approximately 20% to demonstrate noninferiority. Forty-one patients completed the full treatment course. Complete resolution of all symptoms and signs attributable to C. difficile infection during the 3 days after completion of therapy was 87% (20/23 patients) for the vancomycin group, and 94% (17/18 patients) for the nitazoxanide group (95% CI 1830%). RelapsedC. difficile infection was confirmed in two patients in the vancomycin group and one patient in the nitazoxanide group. Therefore, response rates without relapse were 78% and 89% for the vancomycin and nitazoxanide groups, respectively (95% CI 18 35%). Three clinical trials evaluating teicoplanin for C. difficile infection were included in our review.[4345]Teicoplanin is a glycopeptide antibiotic that is similar in structure to vancomycin but is not available for use in the United States. The first study demonstrated no significant differences between vancomycin and teicoplanin in rates of clinical cure (100% vs 96.2%, p=0.56), clinical relapse (20% vs 7.7%, p=0.21), and clinical failure (0 vs 3.8%, p=0.56) in patients from an Italian hospital who were culture positive and/or toxin positive for C. difficile.[43] However, a significant difference in surgical history, a C. difficile infection risk factor, was noted between the vancomycin and teicoplanin groups (90% vs 39%, p=0.0004).

The Swedish C. difficileAssociated Disease (CDAD) trial was a teicoplanin doseranging clinical trial in which patients were randomly assigned to twice-daily dosing of 100 mg for 7 days (b.i.d. group) or 50 mg 4 times/day for 3 days followed by twice-daily dosing of 100 mg for 4 days (q.i.d. group).[44] The average age was 59 years (range 2192 yrs) and 58 years (range 1688 yrs) for the b.i.d. and q.i.d. groups, respectively. The clinical cure rates at the last day of treatment for the b.i.d. and q.i.d. groups, respectively, were 70% and 96% (p=0.02). However, at least one third of the patients in both treatment groups had clinical recurrences within 4 weeks after therapy ended. As a result of the unanticipated high failure rate in the b.i.d. group and the high recurrence rates overall, this study was terminated prematurely. A randomized, comparative study from Austria demonstrated teicoplanin to have the highest clinical cure rate and the lowest clinical relapse rate compared with fusidic acid, metronidazole, and vancomycin.[45]Clinical cure rates, defined as a lack of loose stools, gastrointestinal symptoms, and fever, and normalization of serum C-reactive protein levels and white blood cell counts, were not statistically significantly different (Table 2). Clinical symptoms recurred in 16% of patients treated with vancomycin, 7% treated with teicoplanin, 28% treated with fusidic acid, and 16% treated with metronidazole. No significant differences were noted among relapse rates except for fusidic acid versus teicoplanin (28% vs 7%, p=0.043). This study was distinctive because of the relatively younger average ages of the patients, which ranged from 3845 years among the four treatment groups. Fusidic acid is a bacterial protein synthesis inhibitor with activity against grampositive organisms, including methicillin-resistant Staphylococcus aureus. However, it is not licensed for use in the United States. This agent was compared with metronidazole in two separate studies, both taking place in Sweden.[46, 47] The first trial reported that the proportion of patients clinically cured in the metronidazole group was higher than that in the fusidic acid group (93% vs 83%, p=0.116) on initial follow-up (16 days after treatment).[46] The rates of clinical recurrence after the second follow-up (days 3540) between the two treatment groups were similar and not significantly different (29% for metronidazole vs 27% for fusidic acid, p=0.971). The other trial demonstrated non-inferiority between metronidazole and fusidic acid in terms of permanent cure and eradication of C. difficile infection (Table 2).[47] Of interest, 55% (11/20) of those patients given fusidic acid and who remained culture positive developed C. difficileinfection resistant to fusidic acid. Five (46%) of the 11 patients who developed resistant C.

difficile to fusidic acid were still permanently cured with this agent, compared with 5 (56%) of the 9 patients that had susceptible C. difficile (p=1.0). A prospective, randomized, single-blind clinical trial compared the efficacy of metronidazole with and without rifampin.[48] Case reports of rifampin plus vancomycin have been described as successful in the treatment of relapsing C. difficileassociated diarrhea.[51] In the clinical trial, a patient was considered clinically cured after he or she became asymptomatic during the treatment course.[48] The metronidazole plus rifampin treatment group had a clinical cure rate of 63% versus metronidazole alone at 65% (p=0.91). Clinical relapse was defined as recurrence of diarrhea in those who were clinically cured and was determined through 40 days of follow-up after enrollment. Clinical relapse rates were similar in the metronidazole plus rifampin and metronidazole alone treatment groups (38% vs 42%, p=1.0). Six of 19 patients in the metronidazole plus rifampin group died (one due to C. difficileassociated diarrhea) compared with 1 of 20 patients in the metronidazole alone group (p=0.04). The authors ended the study early as a result of the high mortality rate; however, the patient population evaluated was elderly (mean age 75 yrs) with multiple comorbidities (e.g., renal failure, chronic heart failure, lung cancer). Tolevamer is an anionic polymer that noncovalently binds toxins A and B of C. difficile. A phase II, multicenter, randomized, double-blind clinical trial compared vancomycin with tolevamer in 222 patients.[49] Time to resolution of C. difficile associated diarrhea was the primary end point. This was defined as the first day of 2 consecutive days when the patient had hard or formed stools, or two or fewer stools that were loose or watery. The median time to resolution of diarrhea with vancomycin was 2 days and was found to be noninferior to tolevamer 6 g/day at 2.5 days (p=0.09). Vancomycin was described to achieve the highest cure rate of C. difficileassociated diarrhea and was significantly superior to tolevamer 3 g/day (Table 2).

Treatment of Recurrent Infection

Two double-blind, placebo-controlled studies; one open-label, noncomparative efficacy study; and one phase II drug development study targeting treatment of individuals with recurrent C. difficile infection were included in this review (Table 3).[5255] Enrollment into these studies involved patients who had received a diagnosis of C. difficile infection within a specified time frame and/or had failed initial treatment for C. difficile infection. The average age of patients was 61.4 67.5 years.

The first trial enrolled patients with C. difficileassociated diarrhea from nine hospitals in Sweden who had at least one C. difficile associated diarrhea episode within the 2 months before enrollment.[52] Two treatment groups were provided either metronidazole plus a fruit drink fermented with L. plantarum 299v or metronidazole plus a placebo fruit drink. The primary outcome was a clinical recurrence of C. difficileinfection up until 70 days after initiation of treatment. Recurrence was observed in 4 of 11 patients treated with metronidazole plus a probiotic, and in 6 of 9 patients who received metronidazole plus placebo (36.4% vs 66.7%, p=0.370). Clinical cure was assessed as the cessation of diarrhea within 510 days of treatment initiation. Both treatment groups were found to have similar clinical cure rates (Table 3). The next study enrolled patients from four cities across the United States.[53] Patients who had active diarrhea before antibiotic therapy, were positive for C. difficile (toxin- or culture-positive), and had one or more cases of C. difficileassociated diarrhea within 1 year of study admission were included. Data from this trial were part of a national study that randomly assigned patients to receive S. boulardii or placebo plus a 10-day course of either high-dose vancomycin 2 g/day, low-dose vancomycin 500 mg/day, or metronidazole 1 g/day. Initial cure rates (toxin-negative stool samples) at the end of antibiotic treatment were significantly higher in the high-dose vancomycin group compared with the metronidazole group; however, no significant differences were noted between the low-dose and high-dose vancomycin groups or between the lowdose vancomycin group and the metronidazole group. Patients were followed for a minimum of 2 months to evaluate C. difficileassociated diarrhea recurrence rates. Recurrence ofC. difficileassociated diarrhea was observed in 3 of 18 patients who received high-dose vancomycin and a probiotic, compared with 7 of 14 patients who received high-dose vancomycin and placebo (16.7% vs 50.0%, p=0.05). The probiotic did not significantly reduce the frequency of recurrence of C. difficileassociated diarrhea when combined with either low-dose vancomycin or metronidazole (Table 3). The previously mentioned 2006 study that compared nitazoxanide with metronidazole[41] generated an open-label, noncomparative study that investigated the use of nitazoxanide for recurrent C. difficileassociated diarrhea.[54] Nitazoxanide was given to 35 patients who had received either metronidazole or vancomycin for at least 14 days but had persistent C. difficile associated diarrhea; or on at least two occasions, had an initial response to metronidazole or vancomycin that was followed by recurrence of C. difficile associated diarrhea within 30 days. Twenty-six of 35 patients initially responded

to nitazoxanide, as their symptoms of diarrhea, abdominal discomfort, fever, and/or leukocytosis subsided. However, seven of these patients experienced recurrent C. difficileassociated diarrhea within 60 days of treatment. Response to nitazoxanide was successful after retrying it in three patients who initially failed to respond and in one of the seven patients who had a recurrent episode. A total cure rate was therefore observed in 23 (65.7%) of 35 patients. A recent phase II drug development study evaluated the monoclonal antibodies CDA1 and CDB1 targeted against C. difficile toxin A and toxin B.[55] Two hundred patients receiving oral metronidazole or oral vancomycin for C. difficile infection were enrolled from hospitals across the United States and Canada. Patients were randomly assigned to receive either a single intravenous infusion of CDA1 plus CDB1 or placebo (normal saline infusion) as adjuvant therapy and were followed for 84 days, with the hope of reducing the rate of recurrent C. difficile infection. The average patient age was 64 years (range 20101 yrs). Of the patients in the monoclonal antibody group, 7% (7/101) experienced a recurrent episode of C. difficile infection compared with 25% (25/99) in the placebo group (95% CI 7 29%, p<0.001). The seven patients with recurrent C. difficile infection who were treated with monoclonal antibodies were all inpatients who were significantly older and had a higher index of severity of underlying illness than did the outpatients. The serum levels of antitoxin antibodies in these seven patients did not appear to be lower than those in the monoclonal antibody group who did not have a recurrent episode. In subanalyses, the CDA1 and CDB1 antibody treatment was found to be effective with either concomitant vancomycin or metronidazole treatment in patients with epidemic strain BI/NAP1/027 or nonepidemic strains of C. difficile, and in patients with their first episode of infection or those with multiple previous episodes.

Retrospective Studies on Prophylaxis and Treatment of Clostridium difficile Infection

One group of authors reviewed inpatient medical records for patients prescribed antibiotics between 1999 and 2001 to determine if routine probiotic prescribing affected the frequency or severity of antibiotic-associated diarrhea, specifically caused by C. difficile.[56] The patients' medical records came from a medical center in Arizona and were compared with those of a reference group from a sister hospital where there was no probiotic prescribing. Patients who were undergoing active chemotherapy were excluded from the review. The probiotic

prescribed contained L. acidophilus 5 billion colony-forming units (cfu), B. bifidum 4 billion cfu, and Bifidobacterium longum1 billion cfu/capsule. The rate of C. difficileassociated diarrhea per use of antibiotic in 2001 at the probiotic hospital was 5.5% (16/292 patients) and was 12.1% (25/207) in the nonprobiotic hospital (p=0.0016), in 2000 it was 16.8% (41/244) at the probiotic hospital and 12.2% (23/188) at the nonprobiotic hospital (p>0.05), and in 1999 it was 17.4% (40/230) at the probiotic hospital and 13.3% (24/181) at the nonprobiotic hospital (p>0.05). Based on 19992000 rates of C. difficileassociated diarrhea at the probiotic hospital and adjusted for frequency at the nonprobiotic hospital in 1999, 2000, and 2001, the percent reduction in incidence of C. difficileassociated diarrhea that resulted from probiotic use was 66% (95% CI 3399%, p=0.0027). A retrospective review of medical records from 18 patients receiving care at a Minnesota hospital between 1994 and 2002 was conducted to evaluate nasogastric stool transplantation for the treatment of recurrent C. difficileinfection.[57] Thirteen of the 18 patients were women, and the average age for the overall study group was 73 years (range 5183 yrs). Each subject was pretreated with oral vancomycin 250 mg 3 times/day, 4 days before transplantation to reduce C. difficile load. Subjects were also given omeprazole 20 mg the evening before and the morning of transplantation. After a 90-day follow-up period, 15 patients had complete resolution of diarrheal symptoms, one patient continued to have diarrhea positive for C. difficile, and two patients died of other underlying conditions before expiration of the 90-day follow-up period. Thus, the cure rate for the 16 patients who survived the follow-up period was 94%.

Considerations for Using Alternative Therapies forClostridium difficile

It is difficult to draw firm conclusions from a comparison of studies that differ in design and distinct outcome measures, even after separating the studies according to prophylactic efforts and treatment scenarios. Variable inclusion and exclusion criteria, inconsistent follow-up periods, and lack of agreeable time until assessment of clinical cure across studies reflect the heterogeneity of clinical practice. Also, important factors influencing pharmacologic selection such as adverse effects, ease of administration, and cost were not directly addressed in every study.

The different preparations and strains of probiotics tested, along with variable host factors, make it difficult to determine the usefulness of a particular probiotic agent. One group of authors admitted to the difficulty in extrapolating their findings to other probiotic products, as different bacterial strains and formulations may not have the same reproducible benefits.[33]As these agents are not regulated by the U.S. Food and Drug Administration, the consistency from one product to another remains questionable. Patient characteristics such as age and immunity are also important points to consider when contemplating probiotic therapy. As adults and young children differ in the composition and stability of gut microflora, age-related differences may influence therapies aimed at altering the pathogenesis of C. difficile.[58] Although no serious adverse events due to probiotics were described in any of the four clinical trials,[3336] clinicians should be aware that the use of such agents are not benign. Reports of bacteremias and fungemias with use of Lactobacillus species and S. boulardii probiotic agents have been documented in both immunocompromised and immunocompetent patients.[5963] Therefore, clinicians must take this into account when deciding on the appropriateness of probiotics. Another area of probiotic research involves two nontoxigenic C. difficile strains (types M3 and T7) that have been tested in hamster models in the prevention of infection against historic and current epidemicC. difficile strains. Inoculation of ampicillin-treated hamsters with the M3 strain prevented colonization of the pathogenic C. difficile strain in 15 out of 15 hamsters, whereas 5 of 6 controls (those without M3 inoculation) became colonized with the pathogenic strain.[64] These results have initiated phase I clinical trials for nontoxigenic C. difficile strains that are under way in Switzerland.[65] Overall, the current data do not definitively support the use of probiotics in the prevention or treatment of recurrent C. difficile infection. A systematic review of probiotic efficacy in the prevention of C. difficileassociated diarrhea confirmed that the evidence is lacking.[66] The only clinical trial that demonstrated the possibility of improved clinical outcomes in patients with recurrent C. difficile infection used S. boulardii concomitantly with high-dose vancomycin.[53] In another study, high-dose metronidazole administered with L. plantarum did not show improvement in clinical cure and actually trended toward a lower cure rate than placebo.[52] Until further research concludes otherwise, it is not clinically warranted to use probiotics for preventing or treating C. difficile infection. However, in the prevention of antibiotic-associated diarrhea, more encouraging

evidence supports that probiotic formulations with eitherLactobacillus species or S. boulardii may be reasonable prophylactic measures. For the treatment of C. difficile infection, several agents demonstrated similar efficacy to vancomycin and metronidazole and should be considered as feasible alternative therapeutic agents if available. Nitazoxanide was determined to be a safe and effective treatment for C. difficile colitis. Despite enrollment issues in the study comparing nitazoxanide with vancomycin,[41] the findings from these limited data were encouraging to warrant further investigation. Nitazoxanide demonstrated noninferiority to metronidazole and trended toward more favorable clinical success rates with prolonged courses. However, from a pharmacoeconomic standpoint, replacing metronidazole with nitazoxanide is not recommended. One group of authors included wholesale acquisition costs for 10day treatment courses of nitazoxanide, vancomycin, and metronidazole, which were $316, $618, and $5, respectively.[54] Thus, nitazoxanide may show the greatest advantage in reducing the use of vancomycin by controlling costs and limiting its overuse. Teicoplanin and fusidic acid were compared with metronidazole, vancomycin, and each other in the treatment of C. difficile infection. Both of these antimicrobials are commonly prescribed in European countries but are not available for use in the United States. Teicoplanin had the most favorable results in terms of clinical cure and recurrence rates and is recommended for treatment of diarrhea caused byC. difficile. Fusidic acid demonstrated remarkably quick resistance after its use and should not be indicated for widespread treatment of C. difficile infection. Results from a phase III randomized clinical trial assessing the use of 10-day courses of fidaxomicin 200 mg twice/day against oral vancomycin 125 mg 4 times/day in the treatment of C. difficile infection were reported.[67] This trial included 128 subjects from clinical sites in Europe, the United States, and Canada. Fidaxomicin was found to be as effective as vancomycin in the prevention of recurrent episodes of C. difficileassociated disease including infection by the hypervirulent strain NAP1/027. This trial and the phase II study previously mentioned[40] provide promising results for fidaxomicin in the treatment of diarrhea caused by C. difficile and, if marketed in the United States, may be recommended. However, this agent has been studied only in mild-to-moderate cases of C. difficile infection, and it is unknown how it would compare to pulse dosing of vancomycin for severe cases of C. difficile infection.

Antimicrobials such as rifaximin and tigecycline are other agents that have demonstrated efficacy in vitro against C. difficile. However, clinical trials for these drugs in this setting are lacking. Rifaximin is a minimally absorbed antibiotic that is indicated for use against Escherichia coli traveler's diarrhea. Two case studies involving eight and six patients were treated with rifaximin for recurrent C. difficileassociated disease and reported 88% and 83% response rates, respectively.[68, 69] The glycylcycline antibiotic, tigecycline, has also been successful in the treatment of severe refractory C. difficile infection in four patients.[70] Bacteriotherapy through fecal instillation demonstrated an encouraging cure rate for severe cases of recurrent C. difficile infection; however, clinical trials for this approach to therapy are lacking. The absence of larger prospective studies for this therapeutic option may be due to several challenges. One obstacle is that this approach is indicated only for recurrent C. difficile infection; therefore, it may be difficult to enroll enough patients to adequately power a study, as the target population is limited. In addition, preparation of fecal instillation may be an exhaustive process that requires donor stool specimens and screening of donors for infectious diseases. Finally, this therapeutic approach may have a social stigma attached to it and an additional barrier of patient and practitioner acceptance. More than a dozen case reports have evaluated the role of bacteriotherapy with fecal instillation from donor specimens in the treatment of recurring C. difficile infection. Routes have included enemas, rectal infusion, and nasogastric instillation. Most of these reports have represented complicated cases of individuals who have failed multiple treatment strategies and may have had underlying conditions that would predispose them to initial treatment failure. [71 75] In a 2009 summary on fecal bacteriotherapy instillation, published case reports from 19582008 documented an overall cure rate of 89% in the resolution of recurrent C. difficile infection.[76] Unfortunately, until prospective clinical trials are conducted, fecal bacteriotherapy instillation will likely remain out of the mainstream for treatment of recurrent C. difficile infection.

Conclusion
As rates of C. difficile infection increase and more toxic strains emerge, alternative therapies for prophylaxis and treatment become increasingly important in the clinical setting. Concern is rising over the effectiveness and overuse of

traditional treatment strategies (oral vancomycin and oral metronidazole). As some alternative therapeutic strategies demonstrate promising results in the treatment of C. difficile infection, further studies are needed to confirm preliminary hypotheses.