There are about half a million C. diff infections every year in the United States. About 30,000 people die from them annually.
But if you’ve had C. diff, you’re more likely to get it again. About 1 in 4 people experience a second infection. They then have a 50% to 65% chance of additional episodes.
These repeat infections are known as recurrent infections. “Antibiotics often do a good job of killing C. diff bacteria, but they also kill off good bacteria,” says Bruce Hirsch, MD, an infectious disease specialist at Hofstra/Northwell Medical Center in Manhasset, New York. “As a result, it’s easier for C. diff bacteria to grow back.”
Here’s why recurrent C. diff happens, its risk factors, and how to treat and prevent it.
Why C. diff Comes Back
Clostridioides difficile is a type of bacteria that infects your GI tract. It usually occurs in people who have taken antibiotics. Your intestinal tract normally contains millions of helpful bacteria that help to prevent infection. But antibiotics can kill off these protective bacteria. This can cause C. diff bacteria to multiply and release toxins that damage cells and cause symptoms like diarrhea, stomach pain, and fever.
There are two reasons why you may get another C. diff infection after you’ve had one:
- Relapse. Some of the original C. diff bacteria remain after you finish antibiotic treatment, and you get the same infection.
- Reinfection. You get a different strain of C. diff infection.
It doesn’t really matter whether or not a recurrent C. diff infection is due to reinfection or relapse. They are both treated the same way.
Risk Factors for C. diff Recurrence
Anyone who’s currently or recently been on antibiotics is more likely to develop a C. diff reinfection, says Sahil Khanna, MBBS, MS, a gastroenterologist at the Mayo Clinic in Rochester, Minnesota. “Antibiotics kill off healthy gut bacteria that normally keep C. diff in check,” he says. That means C. diff spores can regrow in your gut and cause an infection. Certain antibiotics, like penicillins, cephalosporins, and fluoroquinolones, are more likely to do this than others.
Other risk factors include:
Hospitalization. Up to 20% of hospitalized patients and half of people in long-term care facilities like nursing homes have C. diff in their poop. They don’t always have symptoms. But if you’re exposed to them in one of these places, you’re more likely to become infected or reinfected.
Age. Your risk to develop C. diff is 10 times greater if you’re 65 or older.
A weak immune system. Having an underlying condition like HIV or cancer or taking medications that suppress your immune system can make it harder for your body to fight off a C. diff infection.
Inflammatory bowel disease. People who have either ulcerative colitis or Crohn’s disease are more likely to develop a recurrent C. diff infection, even if they weren’t previously on antibiotic treatment.
Delayed antibiotic treatment. If you didn’t get medication to treat your C. diff right away, you’re more at risk for recurrence. “It allows an infection more time to grow, so it’s harder for initial antibiotics to get it under control,” explains Khanna.
Certain medications. Drugs to treat acid reflux, like proton pump inhibitors (PPIs) or histamine H2-receptor blockers (H2Bs) raise your chances that you’ll have a recurrent C. diff infection by about 50%. “Since [these drugs] decrease acidity in the gut, it makes it easier for C. diff bacteria to flourish,” says Khanna.
How to Spot a C. diff Recurrence
Symptoms of a C. diff recurrence are similar to initial infection. They include:
- Diarrhea
- Fever
- Stomach pain
- Loss of appetite
- Nausea
If your health care provider thinks you may have a C. diff recurrence, they will take a sample of your poop and send it off to a laboratory for analysis.
How Treatment Changes for Recurrent C. diff
Recurrent C. diff is treated with antibiotics. There are two main ones doctors use:
Fidaxomicin (Dificid). This is a newer antibiotic to kill active C. diff bacteria. “We prefer to use it with recurrent C. diff infections since it impacts fewer healthy gut bacteria,” says Khanna.
Vancomycin. It’s an older antibiotic often used to treat both initial and recurrent C. diff infections. But since it also reduces levels of your helpful gut bacteria, many doctors prefer to use fidaxomicin first, says Hirsch. “It also depends on a patient’s insurance — some require that you try vancomycin first since it’s available as a generic and is less expensive,” he says.
Regardless of which antibiotic your doctor uses, they’ll most likely use it for longer, and at a higher dose, than the treatment you tried before.
But antibiotics aren’t the only treatments recommended for recurrent C. diff. If you’ve had more than one bout of the infection, your doctor will usually recommend something called microbiome-based therapy. These are given once you’ve finished antibiotics. They help to restore helpful bacteria in your gut.
“Antibiotics kill off active bacteria, but they often can’t get rid of all the spores,” says Khanna. “These can then grow into a full-blown active infection.” There are two available:
Live-jslm (Rebyota). This is a liquid that’s made from donor poop. It contains the same bacteria that are found in a healthy gut. It’s given as an enema, which means your doctor inserts it into your rectum through a tube. Studies show it gets rid of recurrent infections in about 70%-80% percent of people who have C. diff for up to two years.
Live-brpk (Vowst). Like Rebyota, live-brpk comes from donor stool. It’s taken as a capsule that only contains helpful gut bacteria. You take four capsules a day for three days on an empty stomach. Studies show that almost 90% of people who take Vowst are recurrence-free at eight weeks after antibiotic treatment, and almost 80% still are at six months.
Most people improve with the treatments listed above. But if you don’t, your doctor may suggest a fecal microbiota transplant (FMT), otherwise known as a poop transplant. A small sample of healthy stool taken from a friend, family member, or a stool bank, is put into your colon. It’s usually done via a colonoscopy, where a thin tube is inserted into your colon to deliver the poop.
“We think sometimes this may be more effective because we’re able to insert the good gut bacteria very far up into the colon, where they can grow more quickly,” says Robert Orenstein, DO, an infectious disease specialist at the Mayo Clinic in Phoenix, Arizona.
FMT is generally very safe but does cause side effects like diarrhea and belly pain in about 20% of patients. In 2019, two patients who were immunocompromised came down with a serious infection when they were injected with poop that contained the bacteria E. coli. Because of this, it’s not recommended for people who are significantly immunocompromised.
How to Prevent C. diff Recurrence
If you’ve had a C. diff infection, there are some things you can do to help avoid a recurrence. Here are some things to talk to your doctor about:
Avoid unnecessary antibiotics. Sometimes you may need them, such as if you develop another bacterial infection, like pneumonia. But sometimes, you don’t.
“We tell all our patients who have had C. diff to call us if their dentist recommends antibiotics before a dental procedure, because they are often not needed,” says Orenstein.
When you do require them, certain antibiotics may be better than others.
“Narrow-spectrum antibiotics, which target a specific range of bacteria, are less likely to kill off other ‘good’ bacteria in your gut,” says Khanna.
Examples of narrow-spectrum antibiotics include older penicillins, macrolides, and vancomycin.
Eat a fiber-rich diet. “Fiber is rich in substances that good bacteria feed on,” says Hirsch. Good sources include:
- Beans
- Grains
- Vegetables
- Fruits
There aren’t studies in humans to show fiber can help to prevent and treat C. diff infections, but animal studies show it may help get rid of it more quickly. Aim for 25 grams of fiber a day. If you can’t easily get it, you can talk to your health care provider about taking a fiber supplement such as psyllium.
Focus on fermented foods. There’s no evidence that probiotic supplements help to prevent recurrent C. diff infections. But some research suggests fermented milk products such as yogurt, kefir, and buttermilk may help protect against an infection if you’re on antibiotics.
“Fermented foods are rich in “good” bacteria like lactobacillus, bifidobacterium, and streptococcus that help to create a healthier gut that may ward off C. diff infection,” says Hirsch. These include fermented milk as well as fermented vegetables such as kimchi and sauerkraut. “These provide a wider spectrum of good gut bacteria than you can get from a single probiotic supplement,” says Hirsch.
Practice good hygiene. C. diff germs are so small you can’t see them. But they can still live on your body or on certain surfaces and make you sick again.
- Wash your hands with soap and water every time you go to the bathroom and before you eat.
- Make sure all the health care professionals you see wash their hands before they examine you. They should also wear a gown and gloves. This way, if they carry C. diff on their body, it’s harder for them to spread it to you.
- Regularly clean high-touch items at home, like doorknobs, electronics, refrigerator handles, toilet handles, and toilet seats.
Wash certain items that can harbor C. diff, like bed linens, towels, and underwear, in hot water and with chlorine bleach. Wear gloves when you throw them in the wash, too, and wash your hands with soap and water afterward.
Takeaways
If you’ve had a C. diff infection, your risk of developing another one is high. You’re more likely to get one if you’re older, have a weakened immune system, are hospitalized, take certain drugs like proton pump inhibitors, or have inflammatory bowel disease. There are newer treatments available, called microbiome-based therapy, to prevent another infection. Careful antibiotic use, good hygiene, and a high-fiber diet rich in fermented foods can also help.
