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Clostridium difficile infection: epidemiology, risk factors and management

Nature Reviews Gastroenterology & Hepatology volume 8, pages 17–26 (2011)Cite this article

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Abstract

The epidemiology of Clostridium difficile infection (CDI) has changed over the past decade. There has been a dramatic worldwide increase in its incidence, and new CDI populations are emerging, such as those with community-acquired infection and no previous exposure to antibiotics, children, pregnant women and patients with IBD. Diagnosis of CDI requires identification of C. difficile toxin A or B in diarrheal stool. The accuracy of current diagnostic tests remains inadequate and the optimal diagnostic testing algorithm has not been defined. The first-line agents for CDI treatment are metronidazole and vancomycin, with the latter being the preferred agent in patients with severe disease as it has significantly superior efficacy. The incidence of metronidazole treatment failures has increased, emphasizing the need to find alternative treatment options. Disease recurrence continues to occur in 20–40% of patients and its treatment remains challenging. In patients with CDI who develop fulminant colitis, early surgical consultation is essential. Intravenous immunoglobulin and tigecycline have been used in patients with severe refractory disease but delaying surgery may be associated with worse outcomes. Infection control measures are key to prevent horizontal transmission of infection. Ongoing research into effective treatment protocols and prevention is essential.

Key Points

  • A dramatic worldwide increase in the incidence of Clostridium difficile infection (CDI) has occurred over the past decade with the emergence of variant epidemic strains

  • Traditional risk factors, such as age, immunosuppression, antibiotic exposure and health-care contact, remain important

  • New CDI populations are emerging, including those with community-acquired disease, children, pregnant women and patients with IBD

  • Metronidazole and vancomycin are the preferred first-line therapeutic agents; however, there is growing concern regarding treatment failure with use of metronidazole

  • Vancomycin is the preferred agent for patients with severe or recurrent CDI, but treatment of recurrent disease remains challenging

  • Infection control measures are essential to prevent horizontal transmission of infection

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Figure 1: The increasing number of hospitalizations complicated by Clostridium difficile infections at acute care hospitals in the US between 1993 and 2008.
Figure 2: A proposed algorithm for the treatment of Clostridium difficile infection.
Figure 3: Comparative efficacy of metronidazole and vancomycin for the treatment of Clostridium difficile infection.

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    Ashwin N. Ananthakrishnan

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Ananthakrishnan, A. Clostridium difficile infection: epidemiology, risk factors and management. Nat Rev Gastroenterol Hepatol 8, 17–26 (2011). https://doi.org/10.1038/nrgastro.2010.190

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