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Clostridium difficile infection: An overview of the disease and its pathogenesis, diagnosis, treatment, prevention and management
Published in
2013
Volume: 4
   
Issue: 4
Pages: 1219 - 1232
Abstract
Clostridium difficile was thought to be nonpathogenic until 1978, when Bartlett et al. identified C. difficile as the source of cytotoxin in the stools of patients with pseudomembranous colitis, a disorder frequently associated with antimicrobial use C. difficile is responsible for both hospital-acquired and community-acquired diarrhea. Clostridium difficile is transmitted via the fecal-oral route, disruption of the gut flora, typically by antibiotics, allows C. difficile to proliferate, thus resulting in infection C. difficileexerts its pathogenic effect mainly through the production of two exotoxins, toxin A and B. Usually, exposure to both antimicrobials andtoxin-producing C. difficile strains is necessary for the development of CDI. Host factors may be as important. CDI has a wide range of manifestations, causing a self-limited mild diarrheal illness to a fulminant life-threatening colitis. The two main risk factors for CDI are antibioticexposure and age older than 65 but other factors shouldalso be considered like the use of laxatives, proton pump inhibitors or H2 histamine as gastric protection, chemotherapy, renal failure, gastrointestinal surgery, nasogastric tube, mechanical ventilation, prolonged hospital stay. The most widely used diagnostic test for the diagnosis of CDI is the enzyme immunoassay (EIA) for toxin A or toxins A and B. Other methods include:an antigen test that detects the mitochondrial enzyme glutamate dehydrogenase (GDH) within C. difficile, used for screening, stool culture, the cytotoxicity cell assay, another highly sensitive and specific method is polymerase chain reaction( PCR), sensitivity being higher than 90% and specificity of 100%. Colonoscopy and flexible sigmoidoscopyalso used in certain situations, abdominal X-ray is used in cases of ileus or toxic megacolon. For treatment different antibiotics are used: metronidazole, Vancomycin is recommended in severe cases, other treatment options include: Fidaxomicin, Nitazoxanide, rifaximin, Teicoplanin, tigecycline, bacitracin,andfusidic acid. Probiotics are found in fermented milk, yogurt, powders and capsules as lactobacillus, bifidobacteria and Saccharomyces boulardii. They act by inhibiting bacterial adhesion to the intestinal mucosa.There are case reports according to which the use of intravenous unspecific immunoglobulin will benefit patients in recurrence, but there is little data in the literature. While the effectiveness of immunoglobulins remains controversial, monoclonal antibodies directedagainst toxins A and B have been shown to be protective against further relapses when compared to placebo, leaving the door open for future research. Fecal transplants or fecal bacteriotherapy is very promising, with success rates greater than 90% in patients with recurrent infections. In this approach, the stool may be introduced by esophagogastroduodenoscopy, colonoscopy or enema [89].In patients with fulminant infection, early surgery is important. Surgery showed a benefit compared to medical therapy, especially in patients with serum lactate >5 mmol/L and/or leukocytosis ≥50 x109/L. Cl.difficile can cause different rare cases including: inflammatory bowel disease (IBD), pseudomembranous colitis (PMC) that lead to death of a 22-year-old female university student following clindamycin treatment for coverage of a tooth extraction due to a dental abscess, the emergence of multidrug-resistant C. difficile PCR ribotype 046 may be detrimental to anti-tuberculosis chemotherapy, a case of C. difficile bacteremia in a patient who had underwent loop ileostomy is reported, mycoticaneurysm causedby C. difficile is also reported, the use of fecal transplantation as a safe and highly effective treatment for recurrent Clostridium difficile infection is repoterd, Clostridium difficile Infection in Infants and Children is reported also, Clostridium difficile is reported to be the first identified autotrophic bacterial pathogen[104], and Clostridium difficile enteritis is also reported.
About the journal
JournalGut Microbes
ISSN09758585
Open AccessNo