Dr Gianluca Ianiro, a member of the UEG Research Committee, spoke to SciTech Europa about some of the challenges posed by C. diff infections and what can be done to combat them.
According to United European Gastroenterology (UEG), Clostridium difficile infection rates have been rising rapidly in Europe and reports of emerging new strains, growing antibiotic resistance, and increased susceptibility in non-hospitalised individuals are of grave concern. Indeed, C. diff infection is the most common cause of hospital-acquired diarrhoea and is associated with significant morbidity and mortality in hospitalised patients.
Combatting C. diff
C. diff infection causes severe diarrhoea, intestinal inflammation and toxin-mediated cell death that, in severe cases, can lead to shock, hypotension, ileus or megacolon. Standard first-line therapies include the antibiotics, vancomycin or metronidazole, which are initially effective in most individuals. Unfortunately, approximately 20% of successfully-treated patients will have an infection recurrence, and many of these will experience multiple recurrences.
SciTech Europa spoke to Dr Gianluca Ianiro, a member of the UEG Research Committee, about some of the challenges posed by C. diff infections and what can be done to combat them.
Antimicrobial resistance is an issue when it comes to C. diff infections. How would you describe the relevant challenges and how could they be met?
Essentially, and this can be a problem with many infections, is that if a C. diff infection occurs, typically we see a progression of the clinical status of the disease from a mild colitis to a severe colitis, which can become life threatening. If this cannot be stopped with antibiotics as a result of resistance, then the infections will simply continue to become more aggressive.
In light of that, where would you like to see research priorities focusing moving forwards?
There are perhaps three main areas where research can have an impact. The first, of course, is research into the development of new antibiotics. Second, the development of synthetic microbial consortia, constructed via synthetic biology approaches, should be a priority as this has great potential. Finally, probiotic mono-cultures could also play a role in the treatment of C. diff infections in the future.
The high reoccurrence rate is also a specific challenge when it comes to managing C. diff, how do you think that could be better approached?
It is now widely held that the most effective approach for the recurrence of C. diff is Faecal Microbiota Transplantation (FMT). However, access to this treatment is restricted in many places around the world at the moment, and that is for a number of reasons. These include the fact regulations limit its use in many countries around the world. There is also a sense that bureaucracy in some hospitals also prevents some physicians from implementing this treatment.
As such, there is a clear need to better disseminate the benefits of FMT so that the reasons for making it available are absolutely clear and to then standardise it. Nevertheless, it is the prevention of C. diff that should remain a priority.
Should more be done to explore the effectiveness of Faecal Microbiota Transplantation in severe and complicated CDI as well in order to modify clinical course and prevent colectomy?
We know that the severe colitis requires more infusions than mild colitis for it to be cured. As such, it is important that we develop an environment in which not only is FMT made more readily available in more locations, but also that it can be received very quickly, which is crucial because you have to react very quickly; in just a day or two, the situation can worsen quite dramatically, potentially then meaning that surgery is the only option left which, of course, has a higher risk of mortality. Thus, particularly with regard to severe colitis, the patient needs to be able to receive FMT quickly and multiple times in order to avoid this.
In 2017, the ECDC published a protocol developed for the surveillance of CDI to address the lack of standardised surveillance in EU Member State. How important is surveillance and what are your thoughts on the ECDC’s protocol and what more would you like to see being done?
We don’t have enough surveillance in Europe, which is indeed a significant issue. Essentially, we need more surveillance in order to better understand the needs of the patients and indeed the healthcare sector, what particular issues C. diff infections pose, the different ways in which these challenges emerge, and so on. There is a sense that this is something that is done very well in the USA, for instance, and so perhaps there are lessons there that Europe can learn from.
This is also true when it comes to control measures which can be implemented in hospitals to try to prevent future outbreaks, in that there has to be knowledge of preventative measures that can be employed, and, currently, this is much better in the USA. As such, there is perhaps a need conduct campaigns to raise awareness in Europe to help boost this.
Can UEG help here?
Yes, absolutely. Indeed, it is already helping by, for instance, involving dedicated elements of its annual congress to C. diff.
Dr Gianluca Ianiro
UEG Research Committee