ENDOSCOPY The management of C. difficile
Focusing on Clostridium difficile infection (C. difficile), Dr Tim Planche, clinical microbiologist and clinical lead for microbiology, St George’s London, shared some alarming figures. “C. difficile causes a severe hospital acquired gastroenteritis and has got a case fatality of around 5% to 20% and, although this has been declining across the UK, rates across the rest of the world remain high and mortalities still remain considerable. “Clinically, it’s not easy to differentiate clostridium difficile diarrhoea from other causes of hospital acquired diarrhoea, and for this reason it’s very important to have laboratory based confirmation of C. difficile. The laboratory diagnosis is made more difficult by the fact that around 10% of inpatients can carry C. difficile asymptomatically. So, differentiating a person with diarrhoea really caused by C. difficile, from one who just happens to be carrying it - and has diarrhoea for another reason, is important. The main way we do this is using the toxin. Currently we’ve got a two or three stage algorithm to detect C. difficile, but I would stress that C. difficile is a clinical diagnosis and so even if the lab tests are negative, patients with a high index of suspicion should still be treated. Highlighting classification, Dr Planche
observed that patients with C. difficile can be classified into mild, moderate and fulminant disease. He added: “There are quite a few
classification systems around, but most of them involve a white cell counter, fever, or evidence of abdominal tenderness. “Current treatment for C. difficile includes metronidazole, vancomycin and fidaxomicin. Oral metronidazole, up until this point, has been recommended for mild disease – although most recent guidelines from the IDSA no longer recommend metronidazole, because of decreasing efficacy reported in the studies, as well as increasing resistance. Vancomycin now should be considered the backbone of most C. difficile treatments. “The fidaxomicin has been shown in good phase three studies to reduce the recurrence rate of C. difficile from around 20% to around 10%. Despite these good efficacy and phase three studies, its relative expense has meant that people quite often prefer fidaxomicin. Although vancomycin costs about £1300 per course, which is expensive for other C. difficile drugs, it’s actually not that expensive when you compare it to drugs used to treat hepatitis C or drugs used for invasive fungal infections.”
Dr Planche emphasised that there are a number of other new therapies becoming available, which are going into phase three studies soon. “These are drugs such as Ramoplanin or Cadazolid,” he said. “Other new therapies are becoming available too. Finally, in terms of therapy options; fecal microbiota transplantation - whereby the stool from a healthy donor is transferred to a patient with recurrent C. difficile - is shown
to be highly effective in a New England journal study, at reducing recurrence rates in patients who have already had recurrent disease - from around 70% to around 10%. “It should be noted however, that this was quite a complex protocol. Patients would have vancomycin for five days, a bowel lavage, then receive the fecal transplant. This can be expensive and also the side effects have been reported – there are a number, including pneumonia. Alternatives such as rectal administration can be available but haven’t been studied quite as much. Rectal administration uses the rectum as a route of administration for medication and other fluids, which are absorbed by the rectum’s blood vessels, and flow into the body’s circulatory system, which distributes the drug to the body’s organs and bodily systems.”
Save the date
Building on the success of this and previous events, BSG has announced two major events for 2019. On 7 to 8 March 2019, BSG Endoscopy Live 2019 takes place at Sage, Gateshead. Featuring state of the art interactive lectures, covering endoscopic training, practice and innovation, the event will also provide ‘meet the expert’ sessions, with the opportunity to ask all your important questions.
The BSG Annual Meeting returns on 17 to 20 Jun 2019 at the SEC, Glasgow. For more information visit
www.bsg.org.uk CSJ
SEPTEMBER 2018
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