Epidemiology of Clostridium difficile-induced intestinal disease

The epidemiology of Clostridium difficile-induced intestinal disease is an intriguing subject about which there are few answers but many remaining questions. Although it is accepted that altered intestinal microecology (usually the result of antimicrobial therapy) is a major predisposition to disease, the details of microbial interactions are not yet known and clearly involve more than simple overgrowth of a resistant member of the resident flora. A variety of reservoirs of C. difficile are recognized. These include endogenous carriage, environmental contamination, and zoonoses, but the relative epidemiologic importance of these varied sources is yet to be determined. Because minor variations in methods for cultivation of C. difficile can markedly affect the ability to detect the organism, even the prevalence of endogenous carriage by various populations is not fully defined. There is good evidence for nosocomial acquisition of disease, but the frequency of this event and the usefulness of preventive measures need to be determined. The development of a typing system would provide a valuable tool for investigating many of the remaining questions. Finally, in addition to the recognized risk factors, which include the apparently predisposing alteration in intestinal microecology and exposure to C. difficile, there appear to be other, as yet undefined, variables that help to determine whether disease will occur. Perhaps the elucidation of the details of the pertinent microbial interactions as well as an understanding of the relevant host-pathogen relationships will provide important insights into the epidemiology of C. difficile-induced disease.