Clinical Review

Prevention and medical management of Clostridium difficile infection

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1296 (Published 12 March 2010) Cite this as: BMJ 2010;340:c1296
  1. J Shannon-Lowe, foundation year 2 in microbiology1,
  2. N J Matheson, specialty registrar in infectious diseases and general medicine2,
  3. F J Cooke, specialist registrar in microbiology1,
  4. S H Aliyu, consultant in microbiology and infectious diseases12
  1. 1Clinical Microbiology and Public Health Laboratory, Health Protection Agency, Addenbrooke’s Hospital, Cambridge CB2 0QQ
  2. 2Department of Infectious Diseases, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital
  1. Correspondence to: N J Matheson nicholas.matheson{at}addenbrookes.nhs.uk
  • Accepted 2 March 2010

Summary points

  • The incidence of Clostridium difficile infection has increased in the past decade

  • National and local surveillance of C difficile infection is crucial to guide implementation of control measures

  • Prudent antibiotic prescribing, correct hand hygiene, use of personal protective equipment, environmental decontamination, and isolation or cohort nursing may prevent infection

  • Treatment is with oral vancomycin or metronidazole, according to disease severity, with escalation of treatment in the event of non-response

The incidence of Clostridium difficile infection in the United Kingdom has increased since the late 1990s.1 High profile outbreaks in the United States, Canada, and northern Europe have been associated with a previously uncommon but highly virulent strain known as ribotype 027. A recent review in the BMJ examined the role of surgery in treating C difficile colitis.2 This review focuses on the prevention and medical management of C difficile infection. Because few randomised controlled trials (RCTs) exist on this subject, our recommendations are based mainly on non-RCT studies and clinical governance reports.

Sources and selection criteria

We searched PubMed and Google Scholar for articles published from 2006 to 2009 on the treatment and prevention of Clostridium difficile infection and screened the reference lists of retrieved publications. We also consulted the Cochrane Library and the recent best practice guidance from the Health Protection Agency.1

Who becomes infected with C difficile?

C difficile can be cultured from the stool of 3% of healthy adults and as many as 35% of hospital inpatients.3 Lower rates of nosocomial colonisation are seen in some studies, and may be dependent on patient population, length of hospital stay, and local infection control procedures.w1 w2 Most colonised people remain asymptomatic. Clinical disease develops when the normal gut flora is disrupted, usually by antibiotic exposure, thereby creating conditions that favour C difficile proliferation within the colon. Although C difficile infections in England have …

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