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  • Review Article
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Treatment of refractory and recurrent Clostridium difficile infection

Nature Reviews Gastroenterology & Hepatology volume 8, pages 330–339 (2011)Cite this article

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Abstract

The incidence of Clostridium difficile infection (CDI) has increased since 2000, with greater numbers of severe cases reported, in part due to the emergence of a hypervirulent strain. Initial therapy with metronidazole is still recommended for mild to moderate CDI, but vancomycin is recommended for first-line therapy of severe CDI. Colectomy could be life-saving for some patients with severe disease that does not respond to maximal medical therapy. Recurrent CDI is a challenge to treat; no single effective therapy currently exists. Treatments include antibiotics, adjunct probiotics, fecal microbiota transplant and immune approaches. This Review discusses the various therapeutic approaches used for the treatment of refractory and recurrent CDI.

Key Points

  • The incidence and prevalence of Clostridium difficile infection (CDI) have been increasing since 2000, with many severe cases occurring due to emergence of a hypervirulent strain

  • Metronidazole remains the mainstay of therapy for mild to moderate CDI but vancomycin should be used in patients with severe disease

  • Early surgical intervention can be life-saving in very ill patients with severe or fulminant disease who do not respond to maximal medical therapy, especially those ≥65 years

  • Patients with IBD have an increased risk of CDI, which can be more severe in these individuals

  • The treatment of recurrent CDI presents a clinical challenge; multiple therapeutic approaches have been tried, but none has been uniformly effective

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Figure 1: Treatment algorithm for recurrent Clostridium difficile infection.

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Acknowledgements

Thanks to Drs Thomas Bendy, Lawrence Brandt, Colleen Kelly and Alexander Khoruts who participated in discussions of proper terminology of the fecal microbiota transplant procedure.

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  1. Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, 325 Ninth Avenue, Box 359773, Seattle, 98104, WA, USA

    Christina M. Surawicz & Jacob Alexander

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C. M. Surawicz and J. Alexander contributed equally to researching data for the article and discussing the content. The contribution of C. M. Surawicz in writing and reviewing/editing the final manuscript was substantially more.

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Correspondence to Christina M. Surawicz.

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Competing interests

C. M. Surawicz has been on the Speaker's bureau for Biocodex. J. Alexander declares no competing interests.

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Surawicz, C., Alexander, J. Treatment of refractory and recurrent Clostridium difficile infection. Nat Rev Gastroenterol Hepatol 8, 330–339 (2011). https://doi.org/10.1038/nrgastro.2011.59

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