Department of Surgery, University of California, Davis, Sacramento, California 95817, USA.
Surg Infect (Larchmt). 2011 Jun;12(3):235-9. doi: 10.1089/sur.2010.080. Epub 2011 Jul 18.
Clostridium difficile infection (CDI) is the primary cause of antibiotic-associated colitis and 15-25% of nosocomial antibiotic-associated diarrhea. Its clinical manifestations can range from mild diarrhea to toxic megacolon, bowel perforation, septic shock, and death. Over the past decade, more virulent strains have become increasingly common causes, and the incidence of CDI has risen, especially in elderly patients. These developments have led to an increase in recurrent CDI, which is more difficult to treat. This review focuses on recurrent CDI and its treatment.
MEDLINE review using search terms Clostridium difficile, Clostridium difficile infection, recurrent Clostridium difficile infection.
A first recurrence may be treated with the same regimen as the first episode. Metronidazole 500 mg q 8 h for 10-14 days is the drug of choice for moderate infection, and vancomycin 125 mg q 6 h for 10-14 days is the drug of choice for severe CDI. Metronidazole should not be used for treatment of subsequent recurrences because of potential neurotoxicity and hepatic toxicity. Second recurrences should be treated with an oral vancomycin course and taper: 125 mg q 6 h × 10-14 days, 125 mg q 12 h × 7 days, 125 mg q 24 h × 7 days, 125 mg q 48-72 h × 2-8 weeks. Alternative agents are fecal bacteriotherapy, a "rifaximin chaser," nitazoxanide, probiotics, and intravenous immunoglobulin. Fidaxomicin has been approved recently. Monoclonal antibodies against C. difficile toxin remain investigational.
Treatment of recurrent CDI remains challenging. Because of the lack of high-quality studies, recommendations for treatment are based on expert opinion. Metronidazole and vancomycin are the mainstays of treatment for both the initial infection and the first recurrence. For second recurrences, a vancomycin course plus taper is recommended. For subsequent recurrences, treatment options are many, with no one approach being entirely satisfactory. New drugs (fidaximicin) and treatments (monoclonal antibodies against the causative toxin) appear promising.
艰难梭菌感染（CDI）是抗生素相关性结肠炎的主要原因，也是 15-25%的医院获得性抗生素相关性腹泻的原因。其临床表现从轻度腹泻到中毒性巨结肠、肠穿孔、感染性休克和死亡不等。在过去的十年中，毒力更强的菌株越来越成为常见的病因，CDI 的发病率上升，尤其是在老年患者中。这些发展导致复发性 CDI 增加，治疗更加困难。本综述重点介绍复发性 CDI 及其治疗。
使用搜索词“艰难梭菌”、“艰难梭菌感染”、“复发性艰难梭菌感染”进行 MEDLINE 综述。
首次复发可采用与首次发作相同的方案治疗。甲硝唑 500mg，每 8 小时 1 次，连用 10-14 天，是中度感染的首选药物；万古霉素 125mg，每 6 小时 1 次，连用 10-14 天，是重度 CDI 的首选药物。由于潜在的神经毒性和肝毒性，甲硝唑不应用于治疗随后的复发。第二次复发应采用口服万古霉素疗程和减量治疗：125mg，每 6 小时 1 次，连用 10-14 天；125mg，每 12 小时 1 次，连用 7 天；125mg，每 24 小时 1 次，连用 7 天；125mg，每 48-72 小时 1 次，连用 2-8 周。替代药物有粪便细菌疗法、“利福昔明追体”、硝唑尼特、益生菌和静脉注射免疫球蛋白。最近批准了菲达霉素。针对艰难梭菌毒素的单克隆抗体仍在研究中。
复发性 CDI 的治疗仍然具有挑战性。由于缺乏高质量的研究，治疗建议基于专家意见。甲硝唑和万古霉素是初始感染和首次复发的主要治疗药物。对于第二次复发，建议使用万古霉素疗程加减量。对于随后的复发，治疗选择很多，但没有一种方法完全令人满意。新药物（菲达霉素）和治疗方法（针对致病毒素的单克隆抗体）似乎很有前途。
