Drs Shapiro and LeLeiko have disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
The American College of Gastroenterology recently released evidence-based guidelines for the diagnosis, treatment, and prevention of Clostridium difficile infections (CDI).1 CDI is the leading cause of hospital-associated diarrhea in the United States and represents a significant burden on health care costs.2 Rates of community-acquired disease are also on the rise, due in part to the recent emergence of a hypervirulent strain, NAP1.
C difficile is a gram-positive, noninvasive bacterium that produces 2 diarrheagenic toxins that are spread via the fecaloral route. The spores of C difficile are not killed by typical alcohol-based sanitizers. Thus, in addition to standard contact precautions, all contacts should wash their hands with soap and water. From a diagnostic standpoint, only patients with diarrheal stools should be screened. Routine testing of infants is not recommended given rates of asymptomatic carriage estimated to be as high as 84.4% in children <2 years of age. Repeat testing and testing for cure are discouraged. While enzyme immunoassay for toxins A and B was the previous diagnostic test of choice, polymerase chain reaction to detect toxin-encoding genes has superior sensitivity and specificity.
Disease classification is central to appropriate therapy. Mild-to-moderate disease consists of diarrhea without systemic complications. Severe CDI criteria include a serum albumin <3 g/dL and a WBC of at least 15,000/mm3 and/or abdominal tenderness. Oral metronidazole remains the treatment of choice for mild-to-moderate CDI. Vancomycin should be considered in patients with severe disease or in those who fail to respond to metronidazole within 5 to 7 days. Initial management of severe and complicated disease should focus on hemodynamics in addition to initiation of antimicrobials. A surgical consult should be obtained in the setting of abdominal distension because of the risk of CDI-associated complications such as paralytic ileus and toxic megacolon. In the absence of abdominal distension, treatment of severe disease should include both oral vancomycin and intravenous metronidazole. Antiperistaltic medications should be avoided because of the risk of obscuring symptoms and precipitating complications of disease.
Recurrent CDI has become an increasingly troublesome complication of infection. While the first recurrence can be treated with the same regimen used for the initial episode, early initiation of vancomycin should be considered in those with comorbid conditions or severe disease. The second recurrence should be treated with a pulsed vancomycin regimen or prolonged taper, although evidence to support either of these approaches is lacking. Recent evidence demonstrating the efficacy of fecal microbiota transplant (FMT) for recurrent CDI is promising. As protocols are yet to be standardized, this recommendation is currently reserved for patients with more than 2 recurrences. However, given preliminary reports of high eradication rates following FMT, one should expect this approach to become more mainstream in the years to come.