Adventures in the microbiome (part 1)

There's a really interesting new paper in Clinical Infectious Diseases on a novel treatment for recurrent C. difficile infection. In this retrospective, uncontrolled experience, 25 patients with recurrent C. difficile infection (mean number of relapses = 4, median days of illness = 135) were treated with either metronidazole or oral vancomycin, along with kefir (5 oz three times daily). The antibiotics were given for 2 weeks at a standard dose (i.e., vancomycin 125 mg every 6 hours). In the next 2 week period, it was given at 3 times standard dose once every 72 hours (i.e., 375 mg), followed by 2 weeks of 2 times standard dose every 72 hours, then 2 weeks of standard dose every 72 hours. This strategy is known as staggered and tapered antibiotic withdrawal (STAW). The kefir was continued for 2 months after the antibiotic was discontinued.

I had to learn about kefir as I knew very little about it. It's essentially milk in which the lactose has been fermented by bacteria. It contains 10 strains of bacteria at a concentration of 7-10 billion CFU/cup. Thus, it's a big gun probiotic, and comes in several different flavors and forms (liquid, frozen, yogurt, cheese). You can find it in most grocery stores.

The end result was that 84% of the patients treated with STAW + kefir were diarrhea-free at 9 months. Again, this was an uncontrolled study, but nonetheless quite intriguing. I will certainly try this regimen in patients with recurrent C. difficile as an option for patients who either don't want to have a fecal transplant or would like to try this before resorting to transplant. I also wonder whether we should be serving kefir to hospitalized, nonimmunosuppressed patients as a prophylactic strategy for C. difficile. This weekend, I'll sample some of the products myself.

Tomorrow, I'll tell you about another interesting manipulation of the gut microbiome.


  1. Thanks for posting this Mike. There has been a lot published on probiotics for prevention (e.g. recent Cochrane Review), but not as much for treatment. Here is a link to a Feb 2014 systematic review on CDI treatments by Nasia Safdar's group: They concluded that: "Overall, the evidence for the adjunctive use of S. boulardii in treating RCDI is moderate. Other probiotic formulations need to be studied for efficacy."


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