Clostridium difficile

Clostridium difficile (CD) is recognised as a major causative agent of antibiotic-associated diarrhoea and colitis [1, 2]. It is found in the normal flora of approximately 2% of healthy adults. Prevalence rises with age and older people have colonisation rates of up to 14% [2, 3]. CD infection is primarily acquired in hospitals and long-stay facilities, most commonly presenting as either mild colitis or watery, mucus-containing diarrhoea with no blood.

Patient management requires withdrawal of any precipitating antibiotics followed by oral metronidazole or vancomycin for 7–10 days [2, 3]. Up to 20% of patients will have a symptomatic relapse on completion of treatment, which can then prove difficult to treat.

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Relapsing CD infection occurs in up to 20% of patients [4]. Usual treatment for a relapse comprises a 7–10 day course of either metronidazole or vancomycin. Subsequent relapse may respond to probiotic therapy [5]. Some patients, however, continue to relapse whenever treatment is discontinued, creating a significant therapeutic challenge.

Cholestyramine binds CD toxin, but is not routinely used as it can also bind vancomycin [2]. There is increasing evidence that the immune response to CD toxin plays a major role in determining susceptibility to recurrent diarrhoea. Several investigators have found that patients with recurrent disease exhibit low antibody levels to CD toxin [4]. In one study of hospital-acquired CD-related diarrhoea, an increase in serum IgG anti-toxin antibody levels was strongly associated with asymptomatic carriage. Lack of antibody response was associated with a 48-fold increase in risk for CD diarrhoea [1]. An immune response to CD toxin may therefore protect against CD diarrhoea.

Intravenous immunoglobulin may effectively treat relapsing CD infection [6–8]. Our patient responded quickly to this intervention when all other treatment strategies had failed over the preceding 6 months. Further study may establish whether intravenous immunoglobulin has a role in routine treatment of recurrent CD infection. Presently it should be considered in cases of repeated relapse where conventional treatment has failed.

extracted from : http://ageing.oxfordjournals.org/cgi/content/full/35/1/85