Clostridium difficile Infection
C. difficile infection (CDI) has become more common as well as more severe. Antibiotics represent the most important, and the most potentially modifiable, risk factor. However, the widespread use of proton pump inhibitors may represent a significant risk
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Key Concepts • The incidence and severity of C. difficile infection is increasing worldwide. • Testing for C. difficile infection has transitioned to the more sensitive nucleic acid amplification tests (NAATs). • Exposure to healthcare facilities, prior antibiotic therapy, and proton pump inhibitor use are common risk factors for infection. • The preponderance of studies suggests that infection with ribotype 027 is associated with worse disease outcomes. • The mainstay of CDI therapy is resuscitation and treatment with metronidazole and/or vancomycin. • Fecal microbiota transplant is a promising emerging therapy. • Surgery can be avoided in most patients but should be considered in cases of continued clinical deterioration despite maximal medical therapy.
Introduction During the previous 20 years, Clostridium difficile infection (CDI) has transitioned from being a relatively uncommon diarrheal illness principally limited to patients rendered immunocompromised from cancer treatment or HIV to a billion dollar per year hospital-acquired infection with a diverse at-risk patient spectrum. Since this epidemiological shift has placed every inpatient at higher relative risk for developing CDI, and considering the potential for this infection to reach a severity requiring surgical intervention as a last resort, a knowledge of Clostridium difficile is important for the general and colorectal surgeon. This chapter reviews the epidemiological changes that have surrounded CDI during the previous two decades, as well as touching upon the key microbiological features of this bacterium that promote CDI and which account for its symptoms. A review of the clinical science directing the proper use of antibiotics against C. difficile is provided, as is a discussion
of surgical treatment options as well as fecal microbiota transplantats (FMT) as an emerging alternative to conventional medical and surgical therapies.
Epidemiology Rising Incidence and Increasing Severity During the previous two decades, and particularly within the previous 15 years, there has been a population level increase in the incidence of CDI both in the United States and in Western Europe [1–3]. Due to greater government funding in European countries, a larger volume of epidemiologic studies and those with the greatest detail related to prevalent strains (ribotypes) of C. difficile [4] have come from Europe. The trends observed in those regions, however, mirror changes in CDI observed in the United States, and this parity between these regional studies provides a similar conclusion when the data is summarized. C. difficile is the predominant form of antibiotic-associated diarrheal illnesses in acute care facilities, and it is reliably estimated to be the causal microbe in at least 15–25 % of such cases [5]. During the previous century, a precipitous increase in the incidence of CDI has been documented; in a study from Quebec evaluating patients from 1991 to 2003, Pepin and colleagues [6] documented a population-level increase of CDI approaching fivefold, while th
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