II. 7 During the course: correct capsule intake and what to avoid

The how matters as much as the what. You will learn the perfect capsule intake – in the morning, on an empty stomach, with plenty of fluid – and you will get to know the pitfalls: antibiotics, probiotics and poor storage.

The perfect intake – step by step

There are living bacteria in your capsule, and our aim is for as many of them as possible to reach your gut alive and active. This is why the way you take it matters so much. The best time is in the morning, immediately after waking, before eating – that is, on an empty stomach. At that point the capsule can set off unhindered to the right place, and the flora^[G] finds the most favourable conditions possible for engraftment^[G].

Always swallow the capsule whole, with plenty of water – do not chew it or open it, because the bacteria inside need protection until they reach their destination. About thirty minutes after taking it, drink another large glass of fluid, preferably still water. After that, breakfast, your other medications and your usual daily routine can follow without concern – once the half-hour has passed, the capsule is already doing its work.

There are two things worth avoiding during intake: do not take the capsule with alcohol or a hot drink, because these can harm the living bacteria. A glass of lukewarm or room-temperature water is the best choice. If you keep to these few simple rules, you get the most out of your capsule.

Fluids – more than enough

One of the main dangers of C. difficile^[G] infection is that diarrhoea carries a great deal of fluid and salt out of your body, which can lead to dehydration. This is why, during the course, conscious hydration is not incidental but a central task. On top of your usual daily fluid intake, drink an extra glass after every looser stool – this replaces what the diarrhoea has taken.

Adequate fluid intake protects above all against dehydration – and it is not unrelated to your gut flora either: the water content of the stool is associated with the richness and composition of the gut flora (Vandeputte 2016 [106]), and daily fluid intake with the flora's composition patterns (Vanhaecke 2022 [107]). These are observed associations, not proven causal chains. It is worth tracking your daily fluid intake (in litres) in your diary, because this is how you see whether you really are drinking enough. If you notice that you are barely passing urine, feeling dizzy or weak, or your urine turns dark yellow, that may be a sign of dehydration – at that point hydration is no longer enough, and you must see a doctor.

What to avoid – antibiotics, probiotics and poor storage

There are three pitfalls that can easily undermine the result of your course. The first is antibiotics: if you are still taking an antibiotic, you must finish it at least 48 hours before starting DiffBiome. The reason is simple – the antibiotic would destroy the freshly delivered beneficial bacteria just as it earlier did your protective flora. The two together make no sense: the antibiotic would remove exactly what the capsule brings in, so the course could not reach its goal.

The second pitfall is probiotics. Although it may seem logical that "more good bacteria is better", during the course leave the shop-bought probiotic preparations aside, unless your doctor expressly says otherwise. DiffBiome delivers a whole, diverse community – the few-strain probiotics can only interfere with this. The third is storage: keep the unopened bottle in a cool, dark place, standing upright, according to the instruction on the label, and open it only to take the dose. If you avoid these three pitfalls, your course works for you with the best chance.

🍽️ Eating during these days

In these three days you practise correct capsule intake and conscious hydration – and your diet complements this, still on the gentle, firming line. Your tasks: take the daily dose in the morning, on an empty stomach, with plenty of water, drink another large glass of fluid 30 minutes later, and on top of your usual daily fluid intake, an extra glass after every looser stool – diarrhoea carries away a great deal of fluid, and replacing it is now a central task.

For these days, the Plant Calendar recommends gentle, stool-normalising sources: on day 22 psyllium husk (psyllium), which is a soluble fibre and a traditional stool-normaliser – always take it with plenty of water – on day 23 rice (a gentle starch, you can start with white, then move to brown), and on day 24 millet (a gluten-free, gentle grain). Soluble fibre forms a gel in water, which supports a firmer stool while your symptoms settle. Build the plant of the day into at least one meal, prepared gently; if you do not tolerate one of them, leave it out and return to it later.

Why does this matter?

Correct intake and avoiding the pitfalls decide how well the living flora in your capsule can take effect. Morning, empty-stomach intake, plenty of fluid, finishing the antibiotic in time and setting probiotics aside all serve to make the delivered bacteria engraft – that is, to make your course truly deliver what you started it for.

References

[005] Kelly C, Fischer M, Allegretti J, LaPlante K, Stewart D, Limketkai B, Stollman N. ACG Clinical Guidelines: Prevention, Diagnosis, and Treatment of Clostridioides difficile Infections. The American journal of gastroenterology. 2021. Link

According to the 2021 ACG guideline, FMT is part of standard care for rCDI; strongly recommended after ≥2 recurrences — American College of Gastroenterology's latest CDI guidelines: FMT strongly recommended after ≥2 CDI recurrences; capsule and colonoscopic administration are equivalent; detailed donor screening and storage protocol; COVID-era updates regarding FMT safety also incorporated.

[023] McDonald LC, Gerding DN, Johnson S, Bakken JS, Carroll KC et al. Clinical Practice Guidelines for Clostridium. difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases. 2018. Link

Comprehensive IDSA/SHEA clinical practice guideline on the diagnosis, treatment and prevention of C. difficile infection in adults and children. It defines severity categories (non-severe, severe, fulminant) and characterises fulminant disease by hypotension or shock, ileus or toxic megacolon — findings that require inpatient care, intravenous therapy and surgical consultation. For multiply recurrent infection in which antibiotic therapy has repeatedly failed, faecal microbiota transplantation is recommended. This document provides the international frame to which the book's red flags and hospital-referral signs are aligned.

[026] Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. American Journal of Gastroenterology. 2016. Link

American College of Gastroenterology clinical guideline on the diagnosis, treatment and prevention of acute diarrhoeal infection in adults. The foundation of care in every form is fluid and electrolyte replacement: oral, with generous fluid and salt intake, in mild and moderate cases, and intravenous in severe dehydration. The guideline sets out the signs by which dehydration is recognised and the groups at risk, and stresses that rehydration is not adjunctive but primary treatment — which is what supports deliberate fluid replacement after every loose stool during the course. The guideline also distinguishes severity levels: **in mild, self-limiting diarrhoea ordinary fluid and food intake is generally sufficient**, whereas **with significant or prolonged fluid loss — particularly in older and vulnerable patients — an oral rehydration solution containing electrolytes is recommended**, not water alone. This is the source for the III.7 claim that plain water and a varied diet suffice in mild diarrhoea, while salt must also be replaced in frequent or persistent diarrhoea. **LIMITATION:** the guideline concerns acute infectious diarrhoea; it does not separately address post-FMT convalescence.

[106] Vandeputte D, Falony G, Vieira-Silva S, Tito RY, Joossens M, Raes J. Stool consistency is strongly associated with gut microbiota richness and composition, enterotypes and bacterial growth rates. Gut. 2016. Link

Based on 16S rDNA profiling of faecal samples from 53 healthy women, stool consistency — measured on the Bristol Stool Scale, which reflects faecal **water content** and, through it, colonic transit time — is strongly associated with microbiota **richness**, composition, enterotype and estimated bacterial growth rates. Looser stool was associated with lower richness and a shift towards the Bacteroides enterotype. Important for the handbook: the article links faecal **water content** to the microbiota — it does NOT claim that fluid intake improves engraftment.

[107] Vanhaecke T, Bretin O, Poirel M, Tap J. **. J Nutr. 2022. Link

Using the American Gut Project database (3,413 and 3,794 faecal samples), the authors examined how drinking water **source** and daily **intake** relate to gut and oral microbiota composition, adjusted for anthropometric, dietary and lifestyle factors. Drinking water source ranked among the key factors explaining gut microbiota variation, and both source and amount were associated with distinct microbiota signatures — including differences in the relative abundance of Campylobacter. Important: this is a cross-sectional association, not causal evidence, and not in an FMT population.