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Clostridium difficile – associated diarrhea Volume 20, issue 2, Février 2013

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Laboratoire «  Clostridium difficile » associé au CNR des anaérobies et du botulisme, Université Pierre et Marie Curie, Groupe de recherche clinique n o2 EPIDIFF, Hôpital Saint-Antoine, unité d’hygiène et de lutte contre les infections nosocomiales (UHLIN), 184 rue du faubourg Saint-Antoine, 75012 Paris, France, Hôpital Saint-Antoine, service de microbiologie, 184 rue du faubourg Saint-Antoine, 75 571 Paris cedex 12, France, Hôpital Saint-Antoine, service de gastro-entérologie et nutrition, 184 rue du faubourg Saint-Antoine, 75 571 Paris cedex 12, France

Clostridium difficile is an anaerobic gram positive, spore-forming bacterium which is responsible for 10 to 25% of antibiotic-associated diarrhea and for more than 95% of pseudomembranous colitis (PMC). C. difficile represents the main cause of nosocomial diarrhea in adults. Virulence is associated with the production of two cytotoxic and enterotoxic toxins (toxins A et B). Main risk factors for C. difficile infections (CDI) include age (>65 y.) and administration of antibiotics. In France, the incidence of CDI has been recently estimated at 2.28 cases for 10,000 patient-days. Since 2003, incidence of CDI has increased worldwide, outbreaks of severe CDI have been reported and CDI seem to be more refractory to standard therapy with metronidazole. This trend is assumed to be associated with the rapid emergence and spread of a specific clone of C. difficile named “027” or “NAP1”. Nosocomial transmission of C. difficile occurs through the hands of healthcare workers and is promoted by the resistance of spores in the environment. Reference methods for CDI are the stool cytotoxicity assay and the toxigenic culture but many laboratories have now moved to molecular methods or two-step algorithms. First line treatment of CDI includes oral metronidazole (500 mg 3×/day); vancomycin (125 mg 4×/day per os) is reserved for severe CDI cases, or in case of intolerance or clinical failure of metronidazole in order to prevent emergence of vancomycin-resistant enterococci. Recurrences occur in 20% of patients and their management remains difficult. Prevention of CDI relies on the restriction use of antibiotics. Cross contamination can be avoided by strict application of contact precautions for infected patients including gloves wearing when entering patient room and disinfection of the environment with detergent-disinfectant active on C. difficile spores.