Clostridium difficile update

Scanning EM of C diff

This review (free full text) was recently published in Southern Medical Journal.

Many C diff reviews have been published in the last few years. This one emphasized several points not covered in previous reviews:

Community acquired C diff is a newly emerging problem. Many patients have no history of recent prior antibiotic usage and lack other traditional risk factors.

C diff can occur in the setting of inflammatory bowel disease. IBD, in fact, is listed as a risk factor for C diff.

Mild disease can evolve into severe disease during treatment.

Leukocytosis may precede GI symptoms, so unexplained leukocytosis developing in a hospitalized patient may be a red flag.

C diff may present as acute abdominal symptoms without diarrhea.

Toxin assays have a sensitivity of only around 70%. Two negative toxin assays in a row, however, are associated with a high negative predictive value.

First recurrences are treated with the regimen to which the patient initially responded unless the recurrence is with severe disease in an patient previously treated with mild disease.

Subsequent recurrences are more problematic. Tapering regimens of vancomycin, pulsed dosing of vancomycin, vancomycin combined with rifampin, or vancomycin followed by rifaximin have been described.

Because alcohol based hand sanitizing agents are not sporicidal, hand washing with soap and water is recommended when caring for such patients.