Announcer
You’re listening to GI Insights on ReachMD, and this episode is sponsored by Nestlé Health Science, a leader in the science of nutrition and gut health. Here’s your host, Dr. Brian McDonough.
Dr. McDonough:
Welcome to GI Insights on ReachMD. I'm Dr. Brian McDonough, and today I'm joined by Dr. Ari Grinspan, who's an Assistant Professor in the Department of Medicine Division of Gastroenterology and the Director of GI Microbial Therapeutics at Mount Sinai, where he pioneered the Fecal Microbiota Transplant Program. He'll be sharing his expert insights on the role of education in managing patients with recurrent Clostridioides difficile infection, also known as C. diff. or CDI. Dr. Grinspan, thank you for being here today.
Dr. Grinspan:
Thank you so much for having me. Looking forward to an informative conversation.
Dr. McDonough:
So am I. And now for some background, Dr. Grinspan, what are the common symptoms and potential complications of recurrent CDI?
Dr. Grinspan:
The classic symptoms of a C. diff infection are what we typically see is; classically, it’s going to be watery diarrhea multiple times a day. There can be comorbid abdominal pain and some nausea, but classically, the major symptom is going to be that watery diarrhea.
You’d think it'd be easy to diagnose somebody with a C. diff infection. It actually turns out to be a little bit more challenging than you’d think. It's not necessarily a black and white diagnosis to make. When patients present with diarrhea, they don't necessarily know our definition of diarrhea. They may say, “Hey, Doc, I’m going the bathroom more often than I should.” But it may not actually be that watery diarrhea that is classic for a C. diff infection. You have to hone in on that question and ask them and have them qualify. When you say you're having diarrhea, what do you actually mean? We have a Bristol Stool Chart that we have in our office, and they can point out what their stool actually looks like. So I can say, yes, that is true diarrhea. That's the most important thing—really understanding what your patient means when they're saying they're having diarrhea.
Dr. McDonough:
So when patients are diagnosed with recurrent C. diff, are there any common concerns or fears they have?
Dr. Grinspan:
There's multiple concerns that our patients have. First and foremost is, “Why me? Why did this happen to me? I did all the things correctly. I took the antibiotics that you prescribed for me. What did I do to allow this to come back?” And the most important thing to remember is that for about 20 percent of patients who get treated for their first infection of C. diff, it's going to come back no matter what the patient does. Even if they're doing all the right things, sometimes it just comes back. It's important to let your patients know that because one of the hallmark symptoms that we see, especially in patients with recurrent C. diff, is a tremendous amount of anxiety about this condition. “I did something. I need to do something differently. It keeps coming back. I can't get rid of it.” And it builds and builds on itself. It becomes very challenging for them to grapple with the fact that they can't get rid of this infection. Most of our patients, when they're thinking about an infection, they're thinking about a urinary tract infection, pneumonia, or a skin infection where one round of antibiotics is all that you need and you're done, it's over. And that's not the case with recurrent C. diff. So that's a major concern from our patients.
The other major concern they have is, “Am I going to give this to somebody else? My kid, my spouse, my dog, my aunt, my uncle, my sick neighbor, my grandparent?” Whatever it may be. And that is something that we have to counsel our patients about. Because yes, C. diff, as we know, is a contagious infection. So if you're in a hospital with a C. diff infection, anybody who comes into the room, they have to gown up and wear gloves because we don't want to pass it on to anybody else. And so talking to our patients about appropriate stewardship at home, about what to do with their loved ones if they have C. diff, and making sure they're washing their hands with soap and water, not using those alcohol swabs, is very, very important as well.
Dr. McDonough:
For those just tuning in, you're listening to GI Insights on ReachMD. I'm Dr. Brian McDonough, and I'm speaking with Dr. Ari Grinspan about educating and managing patients with recurrent Clostridioides difficile infection.
So Dr. Grinspan, now that we've discussed challenges for patients with recurrent C. diff, I'd like to ask you about treatment options. What does the literature tell us about the benefits and risks of antibiotics and microbiome-based therapies?
Dr. Grinspan:
The standard of care treatment for any episode of C. diff is to take antibiotics. You have to treat the active infection and kill the C. diff, and we do that with antibiotics. However, especially with patients with recurrent C. diff, we can't just stop there. We then have to employ prevention strategies. So that's where microbiome-based therapies come into play. There's multiple different therapies that are currently out there that we can use to prevent C. diff from coming back. So after you give them the antibiotic course, you then use these drugs, of which there are several that are now FDA approved, to prevent the next episode of C. diff. And those are all fecal microbiota transplant-related medications.
Dr. McDonough:
With this in mind, how can we ensure a proper treatment administration technique in patient adherence to ensure optimal outcomes?
Dr. Grinspan:
When it comes to the first line, which is antibiotics, there are two medications that are commonly used. One is vancomycin, a four-time-a-day drug. And then there's fidaxomicin, which is a two-time-a-day drug. It's important that we counsel our patients on the importance of taking these antibiotics because that's job number one; we have to kill the infection. But then, to employ one of these microbiome-based strategies—again, this is to prevent the next episode. It's not actually treating that initial or that recurrent episode, it's preventing the next one. There's a couple of different ways to do it. There are encapsulated FMT products, there’s an enema-based FMT product, and there's still a traditional FMT via stool bank, where you deliver that via colonoscopy. So there's a number of different ways that we can administer these drugs, and it's really about talking with your patient about what you think is the best for that particular patient.
Dr. McDonough:
As we come to a close, I just have one last question for you, Dr. Grinspan. In addition to the treatments you discussed, how can we incorporate non-pharmacological approaches to ensure we're caring for the patients holistically?
Dr. Grinspan:
I think the most important thing that we can do for our patients is to be there and listen to them and let them know that they're doing all the right things. I can't emphasize this enough about the anxiety that these patients have, and being there and letting them know that it happens and we have a plan for them in place is important.
Now, in terms of holistic approach, there's not additional therapies that have ever been shown to reduce the risk of C. diff significantly. There is always discussion about using probiotics or different dietary modifications. None of that has really panned out. The most important thing is that we tell our patients, after they get treated for C. diff, they should go back to a healthy diet, incorporating fiber into their diet. Fiber is the good food, the fodder for the microbiome. It will help it be healthy, and that's something that we always should be counseling our patients about.
Dr. McDonough:
With those final thoughts in mind, I'd like to thank my guest, Dr. Ari Grinspan, for joining me to explore how we can better educate and care for patients with recurrent Clostridioides difficile infections. Dr. Grinspan, it was a pleasure having you on the program.
Dr. Grinspan:
Thank you for having me.
Announcer
This episode of GI Insights was sponsored by Nestlé Health Science, a leader in the science of nutrition and gut health. To access this and other episodes in our series, visit GI Insights on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
