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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The capsule is formulated to rehabilitate the human gut microbiome delivering a broad spectrum of live microbes into the patient's intestinal tract. The gut microbiome hosts trillions of microbes that live in harmony with their human host and perform processes vital for health.

“New therapies are urgently needed to prevent recurrent C-diff, a debilitating, costly and potentially life-threatening infection," says Sahil Khanna, M.B.B.S., a gastroenterologist at Mayo Clinic and principal investigator on the study. He says the study will enroll approximately 20 patients in a prospective, two-arm, phase-one, safety assessment and dosing study at Mayo Clinic’s Rochester campus.

MEDIA CONTACT: Joe Dangor, Mayo Clinic Public Affairs, 507-284-5005, newsbureau@mayo.edu

“C-diff infections are an increasingly difficult-to-resolve intestinal infection that cause about 29,000 deaths annually in the U.S.,” says Dr. Khanna.

Dr. Khanna says potential advantages to providing an oral capsule for treatment that is stable at room temperature include flexibility in dosing and at-home treatment. Currently, patients seeking treatment must travel to a medical center for a fecal transplant procedure that involves the placement of live microbes into the patient's body in a procedure similar to a colonoscopy.

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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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Ecosystems usually refer to places on the earth, like forests or deserts. But our bodies have ecosystems, too. Collectively called the "human microbiome," these communities of organisms help keep us healthy. On the next Mayo Clinic Radio, gastroenterologist Dr. Purna Kashyap discusses how the human microbiome works. Also on the program, infectious disease specialist Dr. Pritish Tosh explains when it might be OK to stop taking an antibiotic early. Stool transplantation is being used to treat serious digestive diseases, and gastroenterologist Dr. Sahil Khanna describes how this new treatment works. And physical medicine and rehabilitation specialist Dr. Nathan LeBrasseur talks about ways to slow the aging process.

Myth or Matter-of-Fact: It's OK to stop taking an antibiotic before the prescribed time is up if symptoms have gone away.

Mayo Clinic Radio is available on iHeartRadio.

Click here to listen to the program at 9:05 a.m. CT Saturday, Sept. 5 and follow #MayoClinicRadio.

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Mayo Clinic Radio is a weekly one-hour radio program highlighting health and medical information from Mayo Clinic.

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Myth or Matter-of-Fact: It's OK to stop taking an antibiotic before the prescribed time is up if symptoms have gone away.

Miss the program?  Here's the podcast: MayoClinicRadio 09-05-15 PODCAST

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