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A Review

Eleftherios Mylonakis, MD; Edward T. Ryan, MD; Stephen B. Calderwood, MD

Arch Intern Med. 2001;161:525-533.

Clostridium difficile causes 300 000 to 3 000 000 cases of diarrhea and colitis in the United States every year. Antibiotics most frequently associated with the infection are clindamycin, ampicillin, amoxicillin, and cephalosporins, but all antibiotics may predispose patients to C difficile infection. The clinical presentation varies from asymptomatic colonization to mild diarrhea to severe debilitating disease, with high fever, severe abdominal pain, paralytic ileus, colonic dilation (or megacolon), or even perforation. The most sensitive and specific test available for diagnosis of C difficile infection is a tissue culture assay for the cytotoxicity of toxin B. However, this test takes 1 to 3 days to complete and requires tissue culture facilities. Detection of C difficile toxin by means of enzyme-linked immunoassay is more rapid and inexpensive. A minority of patients may require more than 1 stool assay to detect toxin. Oral metronidazole or oral vancomycin hydrochloride for 10 to 14 days are equally effective at resolving clinical symptoms; oral metronidazole is preferred in most cases because of lowered cost and less selective pressure for vancomycin-resistant organisms. Approximately 15% of patients experience relapse after initial therapy and require retreatment, sometimes with an extended, tapering regimen. Immunity appears to be incomplete and predominantly mediated by serum IgG to toxin A. Measures for preventing the spread of the pathogen, appropriate diagnostic testing, and treatment may avert morbidity and mortality due to C difficile–associated diarrhea.

From the Division of Infectious Diseases, Massachusetts General Hospital (Drs Mylonakis, Ryan, and Calderwood), and the Department of Microbiology and Molecular Genetics, Harvard Medical School (Dr Calderwood), Boston, Mass.

Corresponding author and reprints: Stephen B. Calderwood, MD, Division of Infectious Diseases, Gray-Jackson 504, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114 (e-mail: scalderwood{at}partners.org).

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