Bartlett John G
Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA.
Clin Infect Dis. 2008 Jan 15;46 Suppl 1:S4-11. doi: 10.1086/521865.
The initial period of studies on Clostridium difficile (published during 1978-1980) appeared to provide a nearly complete portfolio of criteria for diagnosing and treating C. difficile infection (CDI). The putative pathogenic role of C. difficile was established using Koch's postulates, risk factors were well-defined, use of a cell cytotoxicity assay as the diagnostic test provided accurate results, and treatment with oral vancomycin was highly effective and rapidly incorporated into practice. During the next 10 years, enzyme immunoassays (EIAs) were introduced as diagnostic tests and became the standard for most laboratories. This was not because EIAs were as good as the cell cytotoxicity assay; rather, EIAs were inexpensive and yielded results quickly. Similarly, metronidazole became the favored treatment because it was less expensive and quelled fears of colonization with vancomycin-resistant organisms, not because it was better than vancomycin therapy. Cephalosporins replaced clindamycin as the major inducers of CDI because they were so extensively used, rather than because they incurred the same risk. Some serious issues remained unresolved during this period: the major challenges were to determine ways to treat seriously ill patients for whom it was not possible to get vancomycin into the colon and to find methods that stop persistent relapses. These concerns persist today.
艰难梭菌研究的初始阶段（发表于1978 - 1980年）似乎为艰难梭菌感染（CDI）的诊断和治疗提供了一套近乎完整的标准。艰难梭菌的假定致病作用通过科赫法则得以确立，风险因素明确，使用细胞毒性试验作为诊断测试可提供准确结果，口服万古霉素治疗效果显著且迅速应用于临床实践。在接下来的10年里，酶免疫测定法（EIAs）被引入作为诊断测试并成为大多数实验室的标准。这并非因为EIAs与细胞毒性试验一样好；而是因为EIAs价格低廉且出结果快。同样，甲硝唑成为首选治疗药物是因为它价格更低且消除了对万古霉素耐药菌定植的担忧，而非因为它比万古霉素治疗效果更好。头孢菌素取代克林霉素成为CDI的主要诱导因素是因为其使用广泛，而非因为它们有相同的风险。在此期间，一些严重问题仍未得到解决：主要挑战是确定治疗重病患者的方法，这些患者无法将万古霉素送达结肠，以及找到阻止持续性复发的方法。这些问题至今仍然存在。
