Abstract
Early and accurate diagnosis is essential for optimal treatment of individuals with Clostridium difficile infection (CDI) and for implementation of effective infection control procedures. The decision about which diagnostic test to use is an important one that should be based on test sensitivity, specificity, and predictive value. The challenges of CDI go beyond rapid identification and management of symptomatic patients. Asymptomatic carriage has long been suspected in C. difficile transmission, but it may play a larger role than previously thought. Emerging information also shows that patients treated for CDI remain colonized for many weeks after symptom resolution. In fact, stool culture positivity increases during the first weeks following treatment completion. Treatments that reduce the duration and degree of asymptomatic shedding could have added benefit for reduced transmission.
Highlights
Difficile transmission, but it may play a larger role than previously thought
MMWR 61(9), Dubberke CID 2012, Miller ICHE 2011, Stabler J Med Microbiol 2008] Much of the increase in Clostridium difficile infection (CDI) incidence, whether in hospitals or the community, is due to emergence of a toxin gene-variant strain, pulse field gel type NAP1 or polymerase chain reaction (PCR) ribotype 027. [Stabler J Med Microbiol 2008, McDonald NEJM 2005, Akerlund J Clin Microbiol 2008, CID 2012] This strain is more virulent, producing more toxin A and B and in addition a third toxin, binary toxin, and it has been highly endemic in the US since about the year 2000
Prior antibiotic treatment is the single most important risk factor for CDI. [CDC MMWR 61(9)] Antibiotic treatment disrupts the normal colonic microbiota, leaving individuals susceptible to CDI when they come in contact with C. difficile spores, which can persist on any surface or device that becomes contaminated
Summary
Incidence of Clostridium difficile infection (CDI) increased dramatically in the first decade of this century and it is the most common healthcare-associated infection in US hospitals. [Lessa NEJM 2015; CDC. The increasing incidence and burden of CDI in the US and other countries (Table 1) has been well described in earlier publications [Lessa NEJM 2015, Dubberke CID 2012, Kwon Infect Dis Clin N Am, 2015], including a recent publication by two authors of this paper. [Eyre NEJM 2013] Another study using molecular subtyping linked 29% of new CDI cases in hospitalized patients directly to asymptomatic persons. [Curry CID 2013] One reason for the increased recognition of the role of asymptomatic carriers in disease transmission may be that improved infection control measures in symptomatic patients have decreased their role in C. difficle transmission. It is important to assess antibiotic exposure because the majority of CDI patients have had antibiotic exposure in the previous 3 months, and to discontinue any current antibiotics. [Hensgens 2012] The decision to treat empirically or to wait for diagnostic test results is dependent on the severity of patient symptoms
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