Clostridium difficile has gone from being just a nuisance or an everyday major problem today. Research has been ongoing to look for better treatment plans and strategies for dealing with relapses. The Infectious Disease Society of America (IDSA) and The Society for for Healthcare Epidemiology of America (SHEA) have released updated guidelines in the May 2010 issue of Infection Control and Hospital Epidemiology.
The guidelines are helpful in reviewing the current state of the art with regards to treating this problem. With the number of remedies and regimens it is important to decide what works and what does not have the science to back it up.
A few points to emphasize from this document that are relevant for day to day practice.
1. Stools should not be checked in asymptomatic patients: This sounds simple enough but unfortunately I get a call almost every week from the lab asking what they should do with a solid stool specimen sent to them for clostridium difficile assay. Stools will remain toxin positive and PCR positive in patients successfully treated for months. There is no value in retesting stools.
2. Repeat testing of stool for toxin during the same episode of diarrhea should not be done.
3. Gloves AND gowns are recommended for all healthcare workers and visitors. There is good evidence that this does reduce nosocomial transmission. This has remained standard practice but unfortunately is often the least adhered to.
4. Private rooms are preferred but if private rooms are not available, cohorting is acceptable with a dedicated commode for each patient.
5. Chlorine containing cleaning agents should be used to reduce spore transmission, there was no recommendations with regards to changing curtains etc.
6. Environmental culture for clostridium difficile is not recommended.
7. Probiotics: Primary use of probiotics to prevent clostridium difficile is not recommended. There are no trials that support the theory that it will prevent clostridium difficile.
8. Metronidazole still remains the first line of therapy it is also recommended for relapse. But should not be used for long term therapy due to risk of neurotoxicity.
9. Treatment of greater than two recurrences can be done with vancomycin with either tapering or pulse treatment. Jury still appears to be out with clear guidelines on what should be done with frequent relapsers.
10. Though is is still very frequently used there is no evidence that use of rifampin or cholestyramine reduces the risk of future recurrence. In fact cholestyramine may delay recovery as it bind to the antibiotics in addition to the toxin.
11. Some practitioners use rifaxamin for the treatment of clostridium difficile with PO vancomycin. The only study on this was small study of 8 patients, where rifaxamin was used immediately after finishing the course of vancomycin it reduced the number of future relapses in 7 of the patients. A very small study and difficult to base widespread use of the agent based on this alone.
12. There is no compelling evidence that use of probiotics are useful in prevention or treatment of clostridium difficile. These agents are widely used with the general feeling that it “cannot hurt”. I am not sure that there is any evidence of this either. In fact there are cases of fungemia due to this.
There is ongoing study in the area of use of immunoglobulin for the prevention and treatment of refractory clostridium difficile. Widespread use cannot still be advocated.
Clostridium difficile remains an important disease and there remains a need for better understanding of the treatment especially in those with frequent relapses and refractory disease.