Clostridium difficile-associated diarrhea: resurgence with a vengeance

There has been a significant increase in the incidence and severity of Clostridium difficile-associated diarrhea (CDAD) in the past several years, including outbreaks in multiple states and provinces in the United States and Canada, as well as in the United Kingdom. A new, highly virulent strain of C. difficile has appeared that is less responsive to standard therapy and associated with a high rate of recurrence. Along with nosocomially acquired infections there has been a rise in the number of community-acquired cases of CDAD, even among those without prior antibiotic exposure. Many factors have contributed to this epidemic, including the development of resistance to the widely used fluoroquinolones class of antibiotics. Because this new strain is less responsive to standard therapy, particularly metronidazole, a number of new antibiotics and other therapies are actively being investigated for use in both primary and recurrent CDAD. A multifaceted approach to managing CDAD is called for, including active surveillance, antibiotic stewardship, and meticulous attention to contact precautions, including gloves, gowns, and hand washing.