A Novel Treatment Approach to Treatment-Resistant, Recurrent Clostridium difficile

Abstract

A 36-year-old male with a previous medical history of persistent Clostridium difficile presented to clinic for evaluation of diarrheal symptoms intermittently for the last 2 years. He reported recurrent episodes of C. difficile that initially began after prophylactic antibiotic use prior to a tooth extraction. He underwent 12 unsuccessful treatment trials at a nearby clinic with courses of vancomycin, metronidazole, and fidaxomicin. His chronic diarrhea had caused him to endure significant lifestyle alterations over the years. After multiple episodes of incomplete bacterial clearance, he was referred to a university-based tertiary care facility but instead opted for care at a nearby clinic. Upon work-up, his serology was again positive for C. difficile, and he was initiated on a 14-day course of fidaxomicin 200 mg p.o. BID, along with yogurt and probiotic supplementation. Despite fidaxomicin treatment, subsequent serological PCR testing for C. difficile remained positive, consistent with CT abdomen and pelvis findings suspicious for enteritis. His recurrent resistance to standard therapy protocols inspired an unconventional treatment approach: another 14-day course of fidaxomicin 200 mg p.o. BID, followed by fidaxomicin 200 mg p.o. each morning and cholestyramine 4 g p.o. each evening for another 2 weeks, concluded by fecal microbial transplant. Two weeks following this antibiotic regimen and fecal transplant, serology was negative for C. difficile. Subsequent follow-up revealed no evidence of recurrence.