Clostridium Difficile

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Contents 1 Introduction 2 Epidemiology 3 Pathology 4 Laboratory 5 Management 6 More General Terms 7 Additional Terms 8 References

Introduction

• A spore-forming obligate anaerobic bacillus best known as the etiologic agent of antibiotic-associated diarrhea ( pseudomembranous enterocolitis). Penicillins, cephalosporins, & clindamycin are the most frequently implicated antibiotics.

Epidemiology

• widely distributed in soil & water
• component of normal fecal flora

• in many infants
• 5% of healthy adults, 15% in Japan
• 20-30% of asymptomatic nursing home patients
• 16-56% of hospitalized patients

• person to person transmission does occur
• spores are hardy & persist for years
• exposure may result in infection or asymptomatic colonization [9]
• associated with diarrhea & colitis with or without pseudomembranes
• neither alchohol nor topical antimicrobials kill C difficile spores - thus handwashing preferred to hand antiseptic for infection control related to C difficile
• virulent strain of C difficile identified [4]

• use of quinolones is specific risk factor

• use of antacids may be general risk factor
• may become airbone from symptomatic patients [8]

Pathology

• enterotoxin A loosens epithelial cell junctions [5]
• enterotoxin B is 100X more cytotoxic than enterotoxin A [5]
• binary enterotoxin
• strains producing large amounts of single toxins

Laboratory

• EIA for toxin A &/or B
• latex agglutination detects glutamate dehydrogenase produced by toxigenic & non toxigenic strains of C difficile & other bacteria
• tissue culture for cytotoxic effects of toxin B
• polymerase chain reaction ( PCR)
• anaerobic stool culture

• 2-3 days
• antibiotic sensitivity testing
• epidemiologic studies

• NOT necessary to test for cure after treatment

Management

• no need to treat asymptomatic persons [3]
• sodium hypochlorite for decontamination of all potentially contaminated surfaces [3]

• alcohol-based hand rubs do not eradicate C difficile spores

• see pseudomembranous enterocolitis
• virulent strain identified in 2005 [5] may be susceptible to oral metronidizole or oral vancomycin

More General Terms

• Clostridium

Additional Terms

• Clostridium difficile enterotoxin A
• Clostridium difficile enterotoxin B
• pseudomembranous enterocolitis (C difficile-associated diarrhea, CDAD, CDD)

References

1. Fekety Am J Gastroenterology 92:739-50 1997
2. Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
3. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; 7th edition 2010
4. McDonald LC, Killgore GE, Thompson A, Owens RC Jr, Kazakova SV, Sambol SP, Johnson S, Gerding DN. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med. 2005 Dec 8;353(23):2433-41. Epub 2005 Dec 1. PMID: [1]
   - Loo VG, Poirier L, Miller MA, Oughton M, Libman MD, Michaud S, Bourgault AM, Nguyen T, Frenette C, Kelly M, Vibien A, Brassard P, Fenn S, Dewar K, Hudson TJ, Horn R, Rene P, Monczak Y, Dascal A. A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med. 2005 Dec 8;353(23):2442-9. Epub 2005 Dec 1. PMID: [2]
   - Centers for Disease Control and Prevention (CDC). Severe Clostridium difficile-associated disease in populations previously at low risk--four states, 2005. MMWR Morb Mortal Wkly Rep. 2005 Dec 2;54(47):1201-5. PMID: [3]
   - Bartlett JG, Perl TM. The new Clostridium difficile--what does it mean? N Engl J Med. 2005 Dec 8;353(23):2503-5. Epub 2005 Dec 1. No abstract available. PMID: [4]
5. Prescriber's Letter 13(1): 2006 Severe infections caused by Clostridium difficile - growing problem Detail-Document#: [5] (subscription needed) [6]
6. Dial S et al, Use of gastric acid-suppressive agents and the risk of community-acquired Clostridium difficile-associated disease. JAMA 2005; 294:2989 PMID: [7]
7. McDonald LC et al, Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003 Emerg Infect Dis 2006; 12:409 PMID: [8]
8. Best EL et al. The potential for airborne dispersal of Clostridium difficile from symptomatic patients. Clin Infect Dis 2010 Jun 1; 50:1450. PMID: [9]
   - Donskey CJ. Preventing transmission of Clostridium difficile: Is the answer blowing in the wind? Clin Infect Dis 2010 Jun 1; 50:1458. PMID: [10]
9. Loo VG et al. Host and pathogen factors for Clostridium difficile infection and colonization. N Engl J Med 2011 Nov 3; 365:1693 PMID: [11]

Clostridium difficile