DEAR MAYO CLINIC: I’ve had recurring instances of C. diff. that normally is treated with antibiotics. I have read about fecal transplant as a potential treatment. How does this work?

ANSWER: Clostridium difficile, also known as Clostridioides difficile and often called C. diff., is a bacterium that causes gastrointestinal symptoms ranging from diarrhea to life-threatening inflammation of the colon. In many cases, antibiotics are an effective treatment. If the infection recurs after two or three rounds of antibiotics, a fecal transplant may be an appropriate alternative.

C. diff. bacteria are found throughout the environment — in soil; air; water; human and animal feces; and food products, such as processed meats. C. diff. is now the most common infection affecting hospital patients. The most common risk factors for C. diff. are taking antibiotics, being older than 65, and being in a hospital or other health care facility.

Taking antibiotics can lead to C. diff. infection by disrupting the healthy balance of bacteria that’s normally present in your intestines. The intestines contain about 1,000–2,000 different kinds of bacteria. Many of them help protect your body from infection. When you take antibiotics to treat an infection, such as for a sinus, urinary tract or kidney infection, those drugs destroy many of the helpful bacteria in the gut along with the bacteria causing the infection. Without enough healthy bacteria to keep it in check, C. diff. quickly can grow out of control.

While antibiotics can contribute to C. diff. infection, some antibiotics, such as vancomycin or fidaxomicin, also can effectively eliminate C. diff. infection. In about 75% to 80% of people who get C. diff., one round of antibiotics is enough to get rid of the infection and prevent it from recurring.

For the other 20% to 25%, a recurrence happens because the antibiotics again take out too much of the good bacteria with the C. diff. Once C. diff. infection recurs, the chances of it returning again after a second round of antibiotics is 40%. After three or more occurrences, the risk of another infection rises to 60%.

One way to break the cycle of recurrent infections is to restore the natural balance of healthy bacteria in the intestines. This can be done through a process known as fecal microbiota transplantation. The procedure — considered investigational at this time — restores healthy intestinal bacteria by placing another person’s processed stool into the colon of a person affected by recurrent C. diff. infections.

Potential donors need to go through a strict screening process that involves an extensive list of medical history questions before they can be approved as donors. They also need to undergo comprehensive testing for infections in the blood and stool.

Once a donor is approved, his or her stool is collected, mixed with saline water and filtered. Then the stool mixture is transferred into the patient’s colon, most commonly via a colonoscope — a thin, flexible tube with a small camera at the tip.

The procedure is considered to be generally safe. The Food and Drug Administration, however, recently released a report about two patients who underwent fecal transplantation and contracted drug-resistant infections. It’s unclear if these cases were related to fecal transplants for C. diff. or if the fecal transplants were done for another condition. More needs to be learned about those incidents, but they speak to the importance of carefully and methodically screening donors.

Clinical trials to study fecal transplants are underway at medical centers across the country, including Mayo Clinic. So far, research has shown that this procedure can reduce the risk of contracting another C. diff. infection in people who have had three or more of the infections. In this patient population, the risk has been reduced from 60% down to less than 15%. With these findings in mind, this treatment appears to show significant promise in providing a more effective treatment option for recurrent C. diff. infections. — Dr. Sahil Khanna, Gastroenterology, Mayo Clinic, Rochester, Minnesota

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The use of microbiome testing – which analyzes the trillions of bacteria in and on the body – is on the move. It’s going from the research lab into the clinic to help guide patient care. DNA testing technologies have revolutionized researchers’ ability to identify individual bacterial strains driving disease. Now genomic testing is helping diagnose the source of infections, develop personalized diets, find new treatments for functional and inflammatory conditions of the gut and identify new screening tools for certain cancers.

For Purna Kashyap, M.B.B.S., this is just the beginning. As the Bernard and Edith Waterman co-director for the Mayo Clinic Center for Individualized Medicine Microbiome Program, Dr. Kashyap envisions the coming years as a pivotal time for moving the latest discoveries from the lab to new diagnostic tests and individualized microbiome-based therapies for patients.

“Just as genomics plays a key role in personalized medicine, the microbiome also affects our individual health – boosting our immune system, helping us digest food and influencing how we respond to medications. We are each born and live with a unique microbiome. But unlike our genes, the microbiome can be manipulated and changed. That’s why physicians need to consider the role of the microbiome, along with genetics and other factors, especially when treating patients with complex diseases like autoimmune disorders, gastrointestinal diseases, diabetes, obesity and many types of cancer,” says Dr. Kashyap.

Technologies developed in the lab provide answers in the clinic

A high fever, increased blood pressure and rapid heart rate – these are all symptoms that could be caused by an infection. But for some patients, traditional blood tests fail to identify the source of the illness. That’s where microbiome testing technologies developed in the laboratory are already helping to find answers for Mayo Clinic patients. Within a day and in some cases just hours, the testing is revealing the source of a previously undiagnosed infection, allowing for treatment with targeted therapies.

“We can now identify the specific bacteria causing serious infections even though we are not able to culture them” says Dr. Kashyap.

Test results can help physicians choose targeted therapies to treat infections and avoid the use of “dynamite” antibiotics explains Dr. Kashyap.

“Genomic testing allows us to select specific therapies to kill only the bacteria causing the infection, rather than prescribing an antibiotic that eliminates all of the gut bacteria, leaving the patient susceptible to other illnesses,” says Dr. Kashyap.

Next steps – identifying biomarkers to predict, diagnose and treat disease

To expand the use of microbiome testing, Dr. Kashyap and his colleagues are collaborating with the Center’s Clinomics Program to integrate microbiome testing into patient care as well as clinical trials. Their goal is to identify microbiome biomarkers that could be used to develop screening tests to detect early signs of disease or new individualized therapies, tailored to a person’s microbiome.

Going forward, microbiome testing may also provide important information about disease risk for healthy patients.

“This testing could provide healthy patients with information about disease risk and help define steps they can take to manage their health,” says Dr. Kashyap.

Eat this, not that – personalized diets

Dr. Kashyap and his colleagues have recently tested a model that successfully predicted changes in blood glucose (sugar) levels based on an individual’s age, lifestyle habits and microbiome.

“With the model, we can manage blood sugar levels by changing diet to match the microbiome rather than trying to change the microbiome which may take time”” says Dr. Kashyap.

Dr. Kashyap and his team have also uncovered a link between a person’s microbiome and their ability to lose weight.

“In a pilot study, we found that after switching to a lower-calorie-diet rich in fruit and vegetables, some people were able to lose weight more easily than others due to the type of bacteria in their gut.”

Learn more about the team’s research here.

Matching research to patient needs – a focus on gut health

Throughout his career as a gastroenterologist, Dr. Kashyap has focused on conducting research to meet the needs of his patients.

He has explored how gut bacteria control normal gut function and contribute to the development of gastrointestinal disorders, such as irritable bowel syndrome.

In addition, he has investigated how bacteria lead to opportunistic infections that can become life threatening, such as c. difficile, which can occur after a patient has had a prolonged stay in a hospital or nursing facility. The Mayo team has used new treatment approaches, including fecal transplants, to restore these patients' gut microbiome with healthy bacteria.

“Some patients have a microbiome composition that makes them more susceptible to c. difficile infection. We are working on strategies to prevent the infection as well as develop a treatment with a bacteria-containing pill.”

For Dr. Kashyap, these research efforts are just the tip of the iceberg. “As we learn more, we’ll be able to offer patients better screening and treatment for a wide range of diseases, tailored to their unique needs.”

Pushing the envelope to uncover causes, new treatments for colorectal cancer

Read the related article, highlighting Microbiome Program co-director Nicholas Chia, Ph.D., and his research to uncover early signs of colorectal cancer to improve screening and treatment for the disease.

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Zika virus and antibiotic-resistant bacteria are among the top infectious disease concerns of health officials, says Dr. Gregory Poland, director of Mayo Clinic’s Vaccine Research Group. Dr. Poland's research team is developing a vaccine for Zika. There is currently no cure or vaccine for Zika. He offered these thoughts on the ongoing crisis.

"Just last month, the head of the Centers for Disease Control and Prevention (CDC) stated that Zika was out of control, and we don't have a way to completely control Zika in the U.S. Our response plan is too little, too late. And I think what he was acknowledging by that is that not that there aren't effective things to do, but this virus came fast, and it had been ignored because the initial outbreaks in Africa and the Pacific had been relatively very minor outbreaks pretty much up  until 2014-2015. We now have local transmission in Florida. We have just recently learned of local transmission in Texas, and we have about 30 or more U.S. states that are at risk. We are in the winter-time right now, but I expect that other than the very Southern rim of U.S., we won't see a lot of activity. But, come spring, I think we are going to be in for a rude awakening in terms of damage this virus can do."

Watch: Dr. Gregory Poland discusses Zika and antibiotic-resistant drugs

The second major infectious disease public health issue, says Dr. Poland, is "the complications of bacteria that are resistant to multiple antibiotics, and particularly as it occurs in hospital settings then diffuses out in the community. We have some very bad bugs that are the result of misuse of antibiotics, primarily in other areas of the world but it occurs in the U.S., too. Anything that occurs anywhere else in the world is only a 12-to-24 hour plane ride to us in the U.S. Some of these bugs, for example Clostridium difficile, can be very difficult to treat. We now have a great option: fecal transplants. Terrible concept, but it is almost like magic in terms of how this works."

Antibiotic resistant bacteria refer to bacteria that have developed resistance to antibiotics that once were commonly used to treat them. In the U. S., at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die each year, according to the CDC.

What you can do to protect yourself from Zika and antibiotic resistant bacteria

• The best defense against Zika virus infection is mosquito bite prevention.
• Understand that common viral infections do not benefit from antibiotic treatment so avoid taking antibiotics unless necessary.

Journalists: Broadcast-quality sound bites are in the downloads.

Review related Zika posts from 2016:

• Infectious Diseases A-Z: The evolving Zika virus and GMO mosquitoes (Nov. 28, 2016)
• Infectious Diseases A -Z: The fight against Zika (Oct. 24, 2016)
• Zika concerns after Hurricane Matthew (Oct. 12, 2016)
• Mayo Clinic offers Zika antibody test via Emergency Use Authorization (Sept. 1, 2016)
• U.S. to screen all blood donations for Zika (Aug. 30, 2016)
• Zika: What you need to know about the CDC travel advisory (Aug. 3, 2016)
• Pediatricians central to Zika patient care (July 25, 2016)
• Non-travel Zika  case spurs concerns: Tips for protection (July 22, 2016)
• Mayo Clinic Minute: Inside a Zika vccine research lab (July 14, 2016)
• Mayo Clinic Minute: Zika-endemic areas (April 22, 2016)
• Zika virus: Four myths and what you need to know (April 18, 2016)
• Zika virus news: Birth defect link confirmed (April 14, 2016)
• Mayo Clinic Minute: Protect yourself from Zika virus (April 8, 2016)
• Zika Virus: CDC guidelines and pregnancy (April 1, 2016)
• Should women wait to get pregnant if traveling to Zika-endemic area? (March 15, 2016)
• Developing a vaccine to protect against Zika virus (March 8, 2016)
• Mayo Clinic begins development of Zika virus vaccine (March 7, 2016)
• Further investigation needed on Zika link to Guillain-Barré Syndrome (March 3, 2016)
• Zika virus and Microcephaly: Need for more research (Feb. 22, 2016)
• Guillain-Barré Syndrome and Zika: Is there a connection? (Feb. 17, 2016)
• Zika virus impacts blood donations (Feb. 5, 2016)
• Transmission of Zika virus and dangers of mosquitoes (Feb. 4, 2016)
• WHO Says microcephaly-Zika virus link international emergency (Feb. 1, 2016)
• Mayo Clinic Minute: Zika virus (Jan. 21, 2016)

Related antibiotic posts from 2016:

• Mayo Clinic Expert Explains 10 Things You Should Know about Antibiotic Resistance (August 18, 2016)
• Understanding Drug-resistant Superbugs (July 7, 2016)
• Antibiotic-resistant Superbug in U.S. (May 27, 2016)
• Resist Overuse of Antibiotics (May 4, 2016)
• Do Ear Infections Always Need to be Treated with Antibiotics? (Jan. 26, 2016)
• Mayo Expert Discusses Antibiotics Overuse and Misuse (Jan. 19, 2016)

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Clostridium difficile

, also called C. difficile, is a bacterium that can cause symptoms ranging from diarrhea, abdominal cramping and fever to life-threatening inflammation of the colon. Some patients with C. difficile do not benefit from standard therapy and the condition frequently comes back.

Now researchers in the Mayo Clinic Center for Individualized Medicine have new hope for selecting the right treatments for patients to stop the infection and alleviate painful symptoms sooner. They have discovered changes in the gut microbiome, the community of bacteria in the digestive tract, that predict how a patient with C. difficile will respond to treatment.

Purna Kashyap, M.B.B.S., of the Department of Gastroenterology and Hepatology, and associate director of the Center for Individualized Medicine Microbiome Program, and colleagues conducted a study of patients with C. difficile, finding gut microbiome signatures that predict treatment response and recurrence. This is important because those patients who will not benefit from the standard antibiotic therapy or have a high likelihood of recurrence can be given alternative therapies sooner. The study of “Gut Microbiome Predictors of Treatment Response and Recurrence in Primary Clostridium Difficile Infection” is published in the Aug. 2 edition of Alimentary Pharmacology and Therapeutics.

“In this study, we identified microbiome markers at the time of initial diagnosis that can predict response to therapy in patients with C. difficile infection. This would allow early identification of patients who are less likely to respond to conventional treatment and candidates for alternate therapy such as fecal microbiota transplant,” says Dr. Kashyap.

The study included 88 patients who had experienced their first episode of C. difficile infection. Researchers collected and analyzed pre-treatment stool samples using DNA-sequencing for the gene encoding 16S rRNA, to identify changes in the gut microbiome. Investigators then correlated these bacterial changes to how well patients responded to treatment, enabling them to identify predictors of treatment response and recurrence.

“This study highlights the utility of next generation microbiome-based precision medicine tools for personalized treatment approaches. Our findings provide an example of how microbiome-based diagnostics can improve patient care by selecting the right treatment for patients,” says Dr. Kashyap.

Each year in the United States, more than half a million people get sick with C. difficile. In the past, C. difficile occurred most frequently in patients taking antibiotics or those over age 65 in a hospital or long term care facility. However, the number of younger, healthy adults with C. difficile is increasing and in recent years, C. difficile infections have become more frequent, severe and difficult to treat.

According to Dr. Kashyap, the next phase of research will focus on validating the findings and developing laboratory tests to identify microbiome predictors.

Additional authors on the research team include Sahil Khanna, M.B.B.S., Robin Patel, M.D., Darrell Pardi, M.D., and Bradley Schmidt, all of Mayo Clinic; Emmanuel Montassier, M.D., Ph.D.,  Université de Nantes, France; and Dan Knights, Ph.D., University of Minnesota.

The study was supported by the Mayo Clinic Center for Individualized Medicine, and grants from the Minnesota Partnership for Biotechnology and Genomics, and National Institutes of Health.

Join us to learn more about the microbiome and other aspects of precision medicine

Learn more about ongoing research efforts in the Center for Individualized Medicine’s Microbiome Program, including current research projects and stories about how this research has helped patients.

Hear experts discuss the latest research in precision medicine, including exploration of the microbiome, and how individualized medicine can improve treatments for many conditions, such as heart disease, cancer, rheumatoid arthritis, Alzheimer's disease and autism.

Attend Individualizing Medicine 2016: Advancing Care Through Genomics. The Mayo Clinic Center for Individualized Medicine, is hosting the fifth annual genomics conference, October 5–6, in Rochester, Minn.

• For a complete schedule and list of speakers, visit the conference website.
• You may also learn more about the conference on the video blog series, “Story by Story.”
• Follow the latest news related to the conference on the Center for Individualized Medicine blog, Facebook, LinkedIn or Twitterat @MayoClinicCIM and use the hashtag #CIMCon16.

The Mayo Clinic Center for Individualized Medicine is hosting the conference with support from the Satter Foundation.

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Written by Dianne Shea

I've been a paraplegic and a Mayo Clinic patient for more than 10 years. My legs decided to stop working over a period of just a few short months due to a spinal tumor. So I didn't think I was a stranger to adversity. Then I met a nasty little bug they call C. difficile. The name is not ironic. At first I thought I had a very violent form of the flu with fevers, chills, vomiting, nausea and (the worst by far) countless, endless bouts of diarrhea.

My days were filled with nothing more than being assisted to the bathroom, cleaning up, getting back into bed, then starting all over again, weaker than before. I required around-the-clock care. I couldn't get dressed, could hardly eat anything, didn't have enough energy to do the smallest of tasks, and couldn't have any fun. Most importantly, I couldn't get through physical therapies for my legs.

I never dared go outside my home (even on holidays) because of the great fear of C. diff acting up. Often my family had to call an ambulance, and I went in and out of hospitals, not staying at  home for any longer than two weeks at a time for the next year. I was terrified that C. diff. would be the thing that made me lose my independence.

I had heard about a new procedure that sounded gross — described as a “fecal transplant” — but that had a huge success rate in solving the C. diff. problem. After losing a year of my life to suffering, I thought I should at least find out about it. And I was put in touch with Dr. Darrell Pardi and Dr. Sahil Khanna from Mayo Clinic.

They were wonderful doctors and educated me on the procedure, its risks and benefits, how it was done, etc. I wanted my transplant as fast as could be arranged! First, I needed a donor. My daughter and son both agreed, but my daughter was the lucky one to go through a few pre-transplant blood tests and checkup. Then I checked into Saint Marys Hospital and did the prep work, which was nothing more than what you would do for a colonoscopy.

The next morning my daughter did her part. (She jokes to this day that she never felt such pressure to do what she does every morning.) Then I was wheeled to the OR. Dr. Pradi had done such a fabulous job preparing me for the procedure that I wasn't worried. The number of doctors and medical personnel that came to the procedure was interesting. I didn't feel, see or hear anything, and the next thing I remember was being told every thing's over, and it all went wonderfully. It wasn't the most fun, but after living with C. diff., it was just another day.

I remember lying in my hospital bed holding my breath and waiting for the cramps, chills, fevers and diarrhea to start. Minutes ticked by. Then hours, nothing. I moved around in bed, nothing. I sat up, nothing. I ate a real meal, with salad, fruit and dairy, but not a cramp, pain, or even the urge to use the bathroom. I slept uninterrupted. (Oh, to know what that felt like again!) I went home still waiting for something to happen, and nothing did. Each day I got stronger, healthier and happier. I started to go out, at first for a few minutes, and then I got really brave and went shopping, got my hair done, went to a movie, and went out to lunch (and ate). My life began again!

I didn't realize how ill I had become until I wasn't ill any longer. I didn't have to worry about being out and unprepared anymore. I could go out and focus on having a good time. It was a miracle. Thanks to the doctors and staff of Mayo Clinic and my family, I have my life back again.

My advice to others: Don't suffer with this disease. Don't be afraid of the procedure, don't wait one more minute, and don't suffer any longer. Start living again.

In the video below, Diane shares more of her story.

The post Life after C. difficile appeared first on Mayo Clinic News Network.

As a result, new treatments are being tested. Mayo Clinic experts are at the forefront of these tests. In June, Mayo Clinic opened a C. Difficile Clinic to provide these treatments to patients.

"New treatment options are now available and we believe that a clinic dedicated to C. difficile will help improve patient care and outcomes," says Sahil Khanna, M.B.B.S., a Mayo Clinic gastroenterologist.

One new treatment available is fecal transplant. Also known as stool transplant, the procedure restores healthy intestinal bacteria by placing donor stool in the colon. Additionally, there is ongoing research on the gut microflora in collaboration with the Center for Individualized Medicine at Mayo Clinic.

Mayo Clinic has expertise in all facets of treatment, including:

• Oral drug therapy
• Fecal microbiota transplantation for recurrent and nonresponding infection
  • Options of related and standardized stool donors
• Clinical trials for new therapies

Journalists: B-roll video of a fecal microbial transplant (FMT) and sound bites with Dr. Khanna are available in the downloads.  Dr. Khanna and Darrell Pardi, M.D., also a Mayo Clinic gastroenterologist, and staff of the clinic are available to discuss c. difficile and treatments by contacting Mayo Clinic Public  Relations at:  newsbureau@mayo.edu

The post C. Difficile: Mayo Clinic Experts on the Latest Treatments appeared first on Mayo Clinic News Network.

"We have seen C.difficile infection as a cause for diarrhea in humans for more than 30 years, and the incidence of infections has been increasing in the last decade," says Sahil Khanna, M.B.B.S., Mayo Clinic Division of Gastroenterology and Hepatology, and lead author of the study. "It has been believed that the typical profile of a person with C. difficile is an older patient, taking antibiotics, while in the hospital. For the first time, we have described a significantly increased incidence of C. difficile in children with diarrhea in a population-based cohort. Importantly, we also found that more than three-quarters of cases of C. difficile in children are being contracted in the community, not in the hospital."

Results of the study showed that the incidence of C.difficile infection (CDI) in children was more than 12 times higher between 2004 and 2009, compared to the period 1991–1997 (32.6 cases per 100,000 vs. 2.6). In addition, 75 percent of cases were "community-acquired," meaning that the patients had not been hospitalized for at least four weeks prior to contracting C. difficile.

C. difficile is an environmental infection, commonly seen on surfaces in the hospital and described to be present in some food sources, including ground beef. Because the infection can be spread from person to person, Mayo Clinic researchers recommend practicing prevention, including:

• Wash hands with soap and water.
• Clean suspected contaminated surfaces with bleach-based solutions.
• Avoid contact with people who are known to have CDI.
• Take extra hygiene precautions if you are living with a person who has CDI or who works in a health care setting where a person might be exposed to patients with CDI.

About Clostridium difficile

C. difficile is a bacterium that is common in the environment. According to the Center for Disease Control and Prevention, approximately 337,000 cases of CDI are reported each year, causing 14,000 deaths. Common symptoms of a mild infection include watery diarrhea two or more times a day for two or more days, and mild abdominal cramping and tenderness. In severe cases, CDI can lead to inflammation of the colon, resulting in fever, blood or pus in the stool, nausea, dehydration, loss of appetite, and significant weight loss.

Other authors of the study include Larry Baddour, M.D.; W. Charles Huskins, M.D., MSc.; Patricia
Kammer, M.D.; Alan Zinsmeister, Ph.D.; W. Scott Harmsen, M.D.; and Darrell Pardi M.D.

###

About Mayo Clinic:

Recognizing 150 years of serving humanity in 2014, Mayo Clinic is a nonprofit worldwide leader in medical care, research and education for people from all walks of life. For more information, visit 150years.mayoclinic.org, www.mayoclinic.org and newsnetwork.mayoclinic.org.

Media Contact: Brian Kilen, 507-284-5005 (days), newsbureau@mayo.edu

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