Clostridium difficile-associated disease: changing epidemiology and implications for management

Clostridium difficile-associated disease (CDAD) is increasingly being reported in many regions throughout the world. The reasons for this are unknown, are likely to be multifactorial, and are the subject of several current investigations. In addition to the upsurge in frequency of CDAD, an increased rate of relapse/recurrence, disease severity and refractoriness to traditional treatment have also been noted. Moreover, severe disease has been reported in non-traditional hosts (e.g. younger age, seemingly healthy, non-institutionalised individuals residing in the community, and some without apparent antimicrobial exposure). A previously uncommon and more virulent strain of C. difficile has been reported at the centre of multiple transcontinental outbreaks. The appearance of this more virulent strain, in association with certain environmental and antimicrobial exposure factors, may be combining to create the 'perfect storm'. It is human nature to be reactive; however, the successful control of C. difficile will require healthcare systems (including administrators, and leadership within several departments such as environmental services, infection control, infectious diseases, gastroenterology, surgery, microbiology and nursing), clinicians, long-term care and rehabilitation facilities, and patients themselves to be proactive in a collaborative effort. Guidelines for the management of CDAD were last published over a decade ago, with the next iteration due in the fall (autumn) of 2007. Several newer therapies are under investigation but it is unclear whether they will be superior to current treatment options.