Epidemiology And Prevention

Toxigenic C. difficile is carried asymptomatically in about 25-80% of infants and in 20% of hospitalized patients, but only in less than 3% of the adult population of developed countries.[11,12] C. difficile-associated disease is primarily a nosocomial infection causing 300,000 to 3 million cases of diarrhea and colitis in U.S. hospitals each year.[5] This pathogen is also responsible for community-acquired diarrhea but at a much lower rate. Epidemiological factors influencing this low incidence in the general population are not fully understood, but the number may be underestimated.1-2-1 Risk factors often associated with C. difficile-associated diarrhea include old age, length and number of hospital stay, and invasive medical procedures. However, the most important factor appears to be the use of antibiotics. The normal bowel flora possess a certain ability to resist colonization by pathogenic microbes. Alteration of this barrier by antibiotics presumably predisposes to invasion by C. difficile and subsequent toxin production. Although virtually all antibiotic molecules have been associated with C. difficile infections, the broad-spectrum antibiotics clindamycin, penicillin, and cephalosporin have been the most frequently implicated. In fact, a recent critical review of the 1978-2001 literature describing the association of antibiotics with nosocomial C. difficile-associated diarrhea concluded that most studies were flawed due to incorrect control groups, inadequate sample sizes, and imprecise analysis of confounding factors.[13] In their opinion, only two studies were of sufficient quality to reasonably establish a causal relationship between particular antibiotic molecules and C. difficile-associated diarrhea, and these molecules were indeed the three listed above. However, this does not exclude other antibiotics from predisposing to the disease.[14] In some institutions, policies limiting the prescription of certain antibiotics appeared to decrease the rate of C. difficile colitis and diarrhea in hospitalized patients.[12] However, decision to restrict the use of some therapeutic molecules has to be weighted against the clinical benefits of using such antimicrobial agents.

Patients contribute to disseminate C. difficile toxigenic strains in hospital settings where endemic and epidemic situations may occur. To prevent cross-contamination of patients with C. difficile, contact precautions must be implemented until diarrhea stops. However, C. difficile spores can survive for months in hospital environments, and patients can be contaminated via contact with care personnel or contaminated objects. Moreover, spores can resist several commercial detergents commonly used to clean surfaces in healthcare institutions. Chlorine-based disinfectants appear to be a better choice and may contribute to reduce the incidence of C. difficile infections.[15] However, to limit C. difficile-associated diarrhea in hospitals, measures must include a combination of rational use of antibiotics and better infection control.[16]

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