Clostridium difficile infection was cited in one of every 250 death certificates completed in the United Kingdom in 2005,1 and it has become the leading cause of death from healthcare associated infections in much of the industrialised world.2 More than 50 000 cases of C difficile infection were reported in England in 2007—a 50-fold increase since 1990.1 Pseudomembranous colitis was first described in 1935, but it took another 40 years for C difficile to be identified as the causative organism.3 4 C difficile associated disease accounts for 15-25% of antibiotic associated diarrhoea,5 and its incidence is rising. The overall prevalence in patients admitted to hospital is around 1%; it can be as high as 20% in those who stay for more than one week and 50% in those who stay for at least four weeks.6 7

This review aims to draw attention to the symptoms of C difficile infection and to summarise evidence on the indications and optimum timing of surgical intervention for C difficile associated colitis. The quality of evidence for the treatment of C difficile associated disease is poor, and the recommendations in this review are based mainly on non-randomised observational studies (level III evidence).