Clostridium difficile associated infection, diarrhea and colitis

Abstract

A new, hypervirulent strain of Clostridium difficile, called NAP1/BI/027, has been implicated in C. difficile outbreaks associated with increased morbidity and mortality since the early 2000s. The epidemic strain is resistant to fluoroquinolones in vitro, which was infrequent prior to 2001. The name of this strain reflects its characteristics, demonstrated by different typing methods: pulsed-field gel electrophoresis (NAP1), restriction endonuclease analysis (BI) and polymerase chain reaction (027). In 2004 and 2005, the US Centers for Disease Control and Prevention (CDC) emphasized that the risk of C. difficile-associated diarrhea (CDAD) is increased, not only by the usual factors, including antibiotic exposure, but also gastrointestinal surgery/manipulation, prolonged length of stay in a healthcare setting, serious underlying illness, immune-compromising conditions, and aging. Patients on proton pump inhibitors (PPIs) have an elevated risk, as do peripartum women and heart transplant recipients. Before 2002, toxic megacolon in C. difficile-associated colitis (CDAC), was rare, but its incidence has increased dramatically. Up to two-thirds of hospitalized patients may be infected with C. difficile. Asymptomatic carriers admitted to healthcare facilities can transmit the organism to other susceptible patients, thereby becoming vectors. Fulminant colitis is reported more frequently during outbreaks of C. difficile infection in patients with inflammatory bowel disease (IBD). C. difficile infection with IBD carries a higher mortality than without underlying IBD. This article reviews the latest information on C. difficile infection, including presentation, vulnerable hosts and choice of antibiotics, alternative therapies, and probiotics and immunotherapy. We review contact precautions for patients with known or suspected C. difficile-associated disease. Healthcare institutions require accurate and rapid diagnosis for early detection of possible outbreaks, to initiate specific therapy and implement effective control measures. A comprehensive C. difficile infection control management rapid response team (RRT) is recommended for each health care facility. A communication network between RRTs is recommended, in coordination with each country's department of health. Our aim is to convey a comprehensive source of information and to guide healthcare professionals in the difficult decisions that they face when caring for these oftentimes very ill patients.

Figure 1

Approach to patients with suspected C. difficile infection.

Figure 2

Initial therapeutic approach to patients with C. difficile infection.

Figure 3

Trends in hospital stays associated with C. difficile-associated disease, 1993-2005. (From Elixhauser and Jhung[82]) shows the trend in CDAD from 1993 through 2005. During the 8-year period from 1993 until 2001, the total number of hospital discharges with CDAD increased from approximately 85 700 to 148 900 per year, 74% increase. However, during the following 4-year period, from 2001 to 2005, the rate of increase for CDAD escalated, when the numbers of cases more than doubled to 301 200 (a 102 percent increase in 4 years). There were a total of 2 037 900 hospital discharges with CDAD over this 12-year period.

Figure 4

Discharge rate for C. difficile-associated disease, per 10 000 hospital discharges, 1993-2005. (From Elixhauser and Jhung[82]) shows the number of CDAD discharges per 10 000 hospital discharges from 1993 through 2005. The findings are similar to those of the previous figure. From 1993 to 2001, the rate of CDAD per 10 000 discharges increased by 60% while the rate of increase from 2001 to 2005 was considerably steeper, 92%. Thus, the recent sharp rise in CDAD was not attributable solely to an increase in the number of hospital discharges.