From the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
J Intern Med. 2021 Aug;290(2):294-309. doi: 10.1111/joim.13290. Epub 2021 Apr 15.
Clostridioides difficile infection (CDI) is an urgent health threat being the most common healthcare-associated infection, and its management is a clinical conundrum. Over 450 000 infections are seen in the United States with similar incidence seen in the rest of the developed world. The majority of infections seen are mild-moderate with fulminant disease and mortality being rare complications seen in the elderly and in those with comorbidities. The most common complication of CDI is recurrent infection with rates as high as 60% after three or more infections. A dilemma in the management of primary and recurrent CDI is testing due to the high sensitivity of the nucleic acid amplification tests such as the polymerase chain reaction, which leads to clinical false positives if patients are not chosen carefully (with symptoms) before testing. A newer testing regimen involving a 2-step strategy is emerging using glutamate dehydrogenase as a screening strategy followed by enzyme immunoassay for the C. difficile toxin. Microbiota restoration therapies are the cornerstone of management of recurrent CDI to prevent future recurrences. The most common modality of microbiota restoration is faecal microbiota transplantation, which has been tainted with heterogeneity and adverse events such as serious infectious transmission. The success rates for recurrence prevention from microbiota restoration therapies are over 90% compared with less than 50% of recurrence prevention with courses of antibiotics. This has led to development and emergence of standardized microbiota restoration therapies in capsule and enema forms. Capsule-based therapies include CP101 (positive phase II results), RBX7455 (positive phase I results), SER-109 (positive phase III results) and VE303 (ongoing phase II trial). Enema-based therapy includes RBX2660 (positive phase III data). This review summarizes the principles of management and diagnosis of CDI and focuses on emerging and existing data on faecal microbiota transplantation and standardized microbiota restoration therapies.
艰难梭菌感染（CDI）是一种紧迫的健康威胁，是最常见的医疗保健相关感染，其管理是一个临床难题。在美国，每年有超过 45 万例感染，在其他发达国家也有类似的发病率。大多数感染为轻度-中度，暴发性疾病和死亡率罕见，见于老年人和合并症患者。CDI 的最常见并发症是复发性感染，三次或更多次感染后的复发率高达 60%。原发性和复发性 CDI 管理中的一个困境是检测，因为聚合酶链反应等核酸扩增检测的敏感性很高，如果在检测前（有症状）没有仔细选择患者，会导致临床假阳性。一种新的两步策略检测方案正在出现，使用谷氨酸脱氢酶作为筛选策略，然后用酶免疫法检测艰难梭菌毒素。微生物组恢复疗法是复发性 CDI 管理的基石，以预防未来的复发。微生物组恢复最常见的方式是粪便微生物群移植，它存在异质性和不良事件，如严重的传染性传播。与抗生素疗程相比，微生物组恢复疗法预防复发的成功率超过 90%，而抗生素疗程预防复发的成功率不到 50%。这导致了胶囊和灌肠形式的标准化微生物组恢复疗法的发展和出现。基于胶囊的疗法包括 CP101（二期结果阳性）、RBX7455（一期结果阳性）、SER-109（三期结果阳性）和 VE303（正在进行的二期试验）。基于灌肠的疗法包括 RBX2660（三期数据阳性）。本文综述了 CDI 的管理和诊断原则，并重点介绍了粪便微生物群移植和标准化微生物组恢复疗法的现有和新出现的数据。
