II. 1. What is Clostridioides difficile?

You get to know your opponent: what C. difficile is, why its spore is so tough, and how its toxins cause your complaints. During your course it is precisely this pathogen that you are pushing back.

What is this bacterium, and where does it come from?

C. difficile is not an exotic, distant pathogen: it can be present in our environment, in the soil and in the gut flora of many people without doing them any harm. Alongside a healthy, diverse gut flora^[G], this bacterium quietly coexists among the others, because the "good" bacteria leave it no room and no nutrients to overgrow. The trouble begins when this balance is upset.

The most common trigger is antibiotic treatment. The antibiotic not only destroys (or reduces the numbers of) the targeted pathogen but also thins out the protective gut flora – this is discussed in detail in the next chapter. In this new composition, C. difficile suddenly gets a free hand: it multiplies and begins to produce the toxins (toxin A and/or B) that cause diarrhoea and inflammation of the gut lining.

It is important to understand: C. difficile infection is therefore not simply a disease you "caught", but rather the consequence of a disrupted internal balance. That is exactly why it is not enough merely to attack the pathogen – for durable recovery the balance of the flora must also be restored, and it is worth examining which factors, alongside the antibiotic, also "helped" the overgrowth. Creating this new balance is the main aim of the book, and perhaps its most important tool is your DiffBiome course.

The spores – why is this pathogen so tough?

One of the most insidious traits of C. difficile is that it forms spores. A spore is like a dormant form sealed in armour: it resists heat, drying out, many disinfectants, and even stomach acid. While conditions are unfavourable, the spore "waits" motionless, but as soon as it finds favourable conditions again in the gut, it germinates, and the bacterium once more becomes active and able to multiply.

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This trait explains why the infection can return so stubbornly, and why it is so hard to eradicate from a hospital environment. Conventional hand-sanitising gels, for example, are not always effective against it – here washing your hands with soap and thorough cleaning of surfaces matter a great deal. The presence of spores is also one of the main reasons why, after a successful antibiotic course, the complaints can rear their head again weeks later: the surviving spores germinate if the gut flora has not yet rebuilt enough to keep them in check.

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The toxins – what causes your complaints?

C. difficile on its own, if it stays quiet, does not necessarily cause symptoms. The complaints – the watery, frequent diarrhoea, the cramping abdominal pain, the bloating – are caused by the toxins it produces. These toxins attack the cell layer covering the inner surface of the bowel wall: they cause inflammation and injury, because of which the bowel cannot properly reabsorb water, and heavy, watery diarrhoea develops.

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This is why it is important to monitor and record your symptoms. The daily number of stools, the consistency of the stool (measured on the Bristol scale^[G]) and whether you see blood in the stool all give a signal about how active the pathogen still is and how inflamed your bowel is. When the course begins to work and the flora rebuilds, the toxin-producing bacteria are pushed back – and as this happens, the symptoms too gradually ease.

Because of the inflammation, the bowel wall can be more fragile, so blood may appear in the stool. This is always a sign to be taken seriously: if you see fresh blood, or if the abdominal pain is strong and accompanied by a tense abdomen on palpation, do not wait – turn to a doctor, as you could also read at the red flags in the Quickstart chapter.

🍽️ Eating during these days

During these three days you get to know what you are up against – the tough spores and the symptom-causing toxins – and meanwhile your task is the conscious observation of your symptoms. Eating supports this phase too: since the inflammation caused by the toxins and the watery diarrhoea take away a lot of fluid, the goal now is a gentle, firming diet – plenty of fluids, easily digestible foods and soluble fibre. Soluble fibre forms a gel in water, which slows the passage of bowel contents and supports a firmer stool, while plenty of fluids replace the amount lost with the diarrhoea. Your concrete tasks: on all three days take the daily dose according to the usual routine, drink an extra glass of water after every looser stool, and on day 5, with soap hand-washing and the clean preparation of food, also reduce the reinfecting effect of the spores.

In this early phase there is not yet a daily plant – the Plant Calendar only starts from day 15. For now stay with easily digestible, boiled or steamed foods, and avoid raw, coarse, strongly gas-forming foods; building up a varied, diverse diet comes later, as the symptoms settle.

References

[346] Lessa FC, Mu Y, Bamberg WM, Beldavs ZG, Dumyati GK, Dunn JR, Farley MM, Holzbauer SM, Meek JI, Phipps EC, Wilson LE, Winston LG, Cohen JA, Limbago BM, Fridkin SK, Gerding DN, McDonald LC. Burden of Clostridium difficile infection in the United States. N Engl J Med. 2015. Link

In an active 2011 population- and laboratory-based surveillance across ten US areas, 15,461 incident C. difficile infection cases were identified. 65.8% were health-care associated, but only 24.2% had hospital-onset disease, indicating that most health-care-associated cases were diagnosed after discharge or in non-acute settings. National estimates derived from regression modeling indicated approximately 453,000 incident CDI cases, 83,000 first recurrences and 29,300 deaths within 30 days of diagnosis annually. NAP1 strains predominated among health-care-associated isolates. The study established CDI as a leading cause of US healthcare-associated infection and a growing community burden.

[365] Reed AD, Theriot CM. Contribution of Inhibitory Metabolites and Competition for Nutrients to Colonization Resistance against Clostridioides difficile by Commensal Clostridium. Microorganisms. 2021. Link

This review examines how commensal Clostridium species mediate colonization resistance against C. difficile. Commensal Clostridia modify primary bile acids into secondary bile acids that suppress C. difficile spore germination and vegetative outgrowth. They additionally produce antimicrobial peptides and short-chain fatty acids that directly inhibit C. difficile and compete for limiting nutrients such as proline, important for C. difficile growth via Stickland fermentation. Loss of commensal Clostridia after broad-spectrum antibiotics is a key mechanistic step toward CDI susceptibility. The authors argue that restoring defined Clostridium consortia is a rational, mechanism-driven alternative to FMT for preventing recurrent CDI.

[369] Weingarden A, González A, Vázquez-Baeza Y, Weiss S, Humphry G, Berg-Lyons D, Knights D, Unno T, Bobr A, Kang J, Khoruts A, Knight R, Sadowsky MJ. Dynamic changes in short- and long-term bacterial composition following fecal microbiota transplantation for recurrent Clostridium difficile infection. Microbiome. 2015. Link

This study tracked fecal microbiota dynamics in four patients with multiply recurrent, antibiotic-refractory C. difficile infection treated with FMT, sampling daily up to 28 days and weekly up to 84 days post-FMT (with sampling out to 151 days). 16S rRNA gene profiling was compared to Human Microbiome Project body-site references. Pre-FMT samples were markedly dysbiotic. FMT produced a rapid normalization of fecal community composition toward a healthy donor-like state within days, and this normalization was largely sustained over months. Time-course visualization highlighted both rapid early shifts and longer-term stabilization. The findings document the kinetics of FMT-driven microbiota recovery in refractory CDI and support its durability.