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Fecal transplants should be considered for patients with recurrent cases of Clostridium difficile whose symptoms cannot be addressed by antibiotics, the Infectious Diseases Society of America said in new guidelines published Thursday.

C. difficile is the most commonly identified cause of healthcare-associated infection in adults in the United States, with half a million cases diagnosed annually. It spreads easily and is particularly dangerous to the elderly and those in long-term care, who have historically been viewed as more vulnerable to infections because of antibiotic use.

The new guidelines reaffirm the need to reduce antibiotic use in such settings and emphasize infection control protocols. But they also change the antibiotics suggested for the treatment of C. diff itself from metronidazole to vancomycin or fidaxomicin.

For the first time, guidelines suggest treating infected patients with donor fecal matter.

“We are now including the recommendation … that they be at least considered for fecal microbiome transplantation,” Clifford McDonald, M.D., associate director for science in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention, told STAT.

But the guidelines acknowledge implementation will be limited by institution size and the financial and laboratory resources available in a particular clinical setting.

For example, Jane Belt, RN, RAC-MT, QCP, curriculum development specialist for the American Association of Nurse Assessment Coordination, questioned the ability of most providers to comply with revised diagnosis protocols.

“The ability for a facility to get necessary lab results really depends on how equipped that lab is,” Belt told McKnight’s. “Not every facility has access to labs that are high-tech. It does depend on the lab services available to a facility – some labs cannot do suggestions.”

Others pointed out that the new preferred diagnostic tests include two- or three-step testing algorithms.

“Multistep testing increases complexity and turnaround time. There is a need for a simple, standalone solution for C. difficile testing, ideally for detection of toxins which we know correlate with outcome,” said John Todd, Sr. Vice President & Chief Scientific Officer at Singulex.

As for fecal transplants, Belt thought the recommendation seems “way out of the scope of LTC.”

“Who is doing the training to get the facility ready?” she asked. “This would need great collaboration.”

McDonald was unavailable for comment on whether the treatment would be  appropriate for elderly patients with co-morbidities or if transplants — still considered investigational by the Food and Drug Administration — would be covered by public or private payers.

But Belt and others said it would serve providers well to study up on the guidelines surrounding diagnosis, antibiotic reduction and infection control.

“I think the real point is the continued reference and great need for better acceptance of the antibiotic stewardship program,” Belt said. “The docs need more education, and what are new guidelines without proper education? We also are concerned most infectious disease physicians do not know, understand or are even willing to work within the regulatory guidelines of SNF or LTC and the antibiotic stewardship programs. We need a great deal of cross education to make this successful in the LTC-SNF world.”