Treatment of Clostridium difficile infections: Old and new approaches

Clostridium difficile remains the most important cause of healthcare-associated diarrhea. A more virulent strain has been identified and has been responsible worldwide for more severe diseases and for higher mortality rates. Clinical data also reported the decreased effectiveness of metronidazole for the treatment of severe disease. Recent American and European guidelines have been published for the treatment of C. difficile infections (CDI). Oral metronidazole (500 mg x 3/d, 10-14 d) is still the drug of choice for the initial episode of mild to moderate CDI. Vancomycin (125 mg x 4/d, 10-14d) should be given orally (or per rectum if ileus is present) in case of severe CDI. Colectomy should be considered in case of severely ill patients (megacolon, septic shock...). Treatment of the first relapse is usually with the same drug as the initial episode. There is no consensus for multiple relapses treatment but vancomycin therapy using a tapered and/or pulse regimen is the preferred next strategy. New developments including new drugs (fidaxomixin) or passive or active immunization are ongoing. (C) 2011 Elsevier Masson SAS. All rights reserved.