From the Guidelines
Antibiotic use is a significant risk factor for Clostridioides difficile (C. diff) colonization and subsequent infection, and therefore, antibiotics should be used judiciously and only when clearly indicated. The relationship between C. diff colonization and antibiotic use is well-established, with antibiotics disrupting the normal gut microbiota and creating an environment where C. diff can thrive 1. The most important modifiable risk factor for the development of C. diff infection is exposure to antibiotic agents, with certain classes such as third-/fourth-generation cephalosporins, fluoroquinolones, carbapenems, and clindamycin being high-risk 1.
Key Points to Consider
- The disruption of the intestinal microbiota by antibiotics is long-lasting, and the risk of C. diff infection increases both during therapy and in the 3-month period following cessation of therapy 1.
- The highest risk of C. diff infection appears to be during and in the first month after antibiotic exposure, with even limited exposure, such as single-dose surgical antibiotic prophylaxis, increasing a patient's risk of C. diff colonization and symptomatic disease 1.
- To minimize the risk of C. diff infection, narrow-spectrum antibiotics are preferred over broad-spectrum ones when appropriate, and the duration of antibiotic therapy should be limited to the shortest effective course 1.
- For patients with a history of C. diff infection, antimicrobial stewardship is particularly important, and alternative non-antibiotic treatments should be considered when possible 1.
Recommendations for Practice
- Use antibiotics judiciously and only when clearly indicated, taking into account the potential risks and benefits of antibiotic therapy 1.
- Choose narrow-spectrum antibiotics over broad-spectrum ones when appropriate, to minimize the disruption of the normal gut microbiota 1.
- Limit the duration of antibiotic therapy to the shortest effective course, to reduce the risk of C. diff infection and colonization 1.
- Consider alternative non-antibiotic treatments for patients with a history of C. diff infection, and prioritize antimicrobial stewardship in these cases 1.
From the Research
Relationship Between C. diff Colonization and Antibiotic Use
- The use of antibiotics is a major risk factor for Clostridioides difficile (C. diff) colonization and infection, as it disrupts the intestinal microbial composition, enabling C. difficile colonization and toxin production 2, 3, 4.
- The risk of C. diff infection is dose-related and higher with longer courses and combination therapy of antibiotics 3.
- Antibiotic exposure is the most important modifiable risk factor for C. diff infection, and responsible antibiotic prescribing is crucial for prevention 3, 5.
- Asymptomatic colonization with C. diff is common, but the risk of infection differs significantly between cohorts, and colonization is not believed to be a direct precursor for infection 4.
Factors Promoting C. diff Infection
- Older age, recent hospitalization, multiple comorbidities, use of gastric acid blockers, inflammatory bowel disease, and immunosuppression are associated with an increased risk of C. diff infection 3, 4.
- The incidence and severity of C. diff infection have increased in recent years, and it has become more common in younger, healthier patients in community settings 3, 6.
Treatment and Prevention
- Discontinuing the contributing antibiotic, if possible, is an important step in treating C. diff infection, and vancomycin and fidaxomicin are recommended as first-line treatments 2, 3, 5.
- Fecal microbiota transplantation (FMT) has emerged as a promising therapy for recurrent C. diff infection, with success rates of over 85% 6.
- Prevention of C. diff infection includes responsible antibiotic prescribing, vigilant handwashing, and antibiotic stewardship, as well as discontinuation of chronic acid suppressive therapy 3, 5.