Preventing downstream Clostridium difficile infections with upstream antibiotic management

Clostridium difficile infection (CDI) remains a devastating cause of hospital-acquired diarrhea. Treatment modalities have centered traditionally on two antibiotics, metronidazole and oral vancomycin. Both drugs, however, have been associated with variable relapse rates up to 20%. Fidaxomicin, a new oral agent with targeted C. difficile activity, may reduce the chance of relapse, but has not yet entered mainstream clinical practice. CDI is associated with significant morbidity and mortality. In the past decade, the emergence of hypervirulent strains has led to medical management failures and the increased need for surgical intervention. Control of the disease requires excellent infection prevention practices, yet can remain a difficult operational challenge. Selective pressure of antibiotic therapy can increase or lessen the risk depending on the agent used. We believe that antibiotic selection for the treatment of patients with any infectious disease must account for the possibility of subsequent severe CDI. We posit 'upstream' antibiotic selection will prevent 'downstream' CDI and potentially ameliorate deficiencies in infection prevention practices. Formal studies evaluating such an endpoint would be useful in this era of dangerous CDI.