spores to develop into vegetative cells between doses, making them susceptible to killing by
antibiotics. Patients requiring antibiotics for other indications in the setting of recurrent CDI
should continue CDI treatment throughout the antibiotic course and for an additional week
postcompletion. Recovery of normal fecal flora may take days to weeks after discontinuation of
antibiotics (61).
Aside from cost, repeated courses of anticlostridial therapy have the disadvantage of
perpetuating this disruption in intestinal flora. To break this cycle, alternate treatments have
been attempted, including probiotics, administration of nontoxigenicC. difficile(62), and stool
transplantation.
Probiotics, includinglactobacillusspecies andSaccharomyces boulardii, are nonpathogenic
microorganisms that, when ingested, may benefit the health or physiology of the host.
Probiotics have been beneficial in the setting of travelers’ diarrhea, rotavirus infection, and in
reducing the incidence of simple AAD but their efficacy in preventing CDI is inconsistent (63).
They are not effective as solo therapy for active infection but the use of probiotics as an
adjunctive therapy in recurrent CDI is widespread.
Stool transplantation, administration of feces or fecal flora via enema, or nasogastric tube
has been found effective in small case series of patients with at least two relapses (61); the
method remains unpopular for practical and aesthetic reasons.
Because the host immune response toC. difficileis thought to play a major role in
recurrent CDI, passive immunotherapy with IVIG has been studied in small series of patients
with recurrent or refractory CDI (27). Anecdotal reports show that IVIG produce a marked
increase in serum antitoxin A/B levels, and resolution of diarrhea (62). Further studies are
needed to confirm these results.OUTCOME
Pre-epidemic strain B1/NAP1 studies showed that with appropriate treatment, the overall
mortality for CDI is<1% in most series but as high as 24% among critically ill patients. Among
patients requiring surgery, mortality rates after colectomy have ranged from 38% to 80% in
small series (40).
Pepin et al. studied the changes in mortality before and after the emergence of the new
epidemic strain (B1/NAP1) and found that the proportion of cases that were complicated
increased from 7.1% in 1991–1992 to 18.2% in 2003 and the proportion of patients who died
within 30 days after diagnosis increased from 4.7% in 1991–1992 to 13.8% in 2003 (10).INFECTION PREVENTION AND CONTROL
Prevention and control of CDI requires restriction in the use of antibiotics and aggressive
infection control measures including specific hand washing protocols, isolation of infected
patients, and appropriate environmental cleaning strategies (45). (Table 4).
After patients have been diagnosed or strongly suspected to have CDI, patients should
be placed on contact precautions in private rooms, if possible. During epidemics or if private
rooms are not available it may be necessary to cohort patients to certain designated rooms.
Each patient should have a dedicated commode, and privacy curtains should be used to
decrease direct contact between beds. As the patient’s symptoms resolve, they should beTable 4 Infection Control
Antimicrobial stewardship
. Restriction of antibiotics associated with increased risk of CDI
Reducing unnecessary use of antibiotics
Reducing duration of antibiotic courses
. Switch from oral to parenteral therapy when possible
- Infection control
. Proper environmental disinfection
Hand hygiene compliance
. Use designated individual thermometers, blood pressure cuffs and stethoscopes for infected patients
Single-room isolation/cohorting
284 Hjalmarson and Gorbach