Epidemiology of nosocomial Clostridium difficile diarrhoea

Clostridium difficile is a frequent and clinically important cause of diarr hoea that has been strongly but not exclusively associated with the hospita l setting. The vast majority of cases of C. difficile diarrhoea are associa ted With antecedent treatment with antibiotics, of which cephalosporins and clindamycin appear to pose the highest risk. Within hospitals and chronic- care facilities, cross-infection of C. difficile has been related to transi ent carriage on hands of healthcare workers and contamination of diverse en vironmental surfaces, including electronic rectal thermometers. Prospective epidemiologic studies have demonstrated that acquisition of C. difficile i s common in hospitalized patients. Although colonized patients contribute t o nosocomial transmission of C. difficile, symptom-free carriage of C. diff icile appears to reduce risk of subsequent development of C. difficile diar rhoea. Antimicrobial treatment with oral metronidazole or vancomycin to att empt to eradicate symptomless carriage is not recommended. Measures to cont rol nosocomial C. difficile diarrhoea have focused on improved handwashing, use of barrier precautions with Single rooms for symptomatic patients, red uction of environmental contamination, and antibiotic restriction Restricti ng clindamycin has been particularly successful in terminating outbreaks of C. difficile diarrhoea associated with its use. The epidemiologic features of C. difficile and strategies for control are similar to those for micro- organisms that have acquired antimicrobial resistance. C. difficile may be indirectly or directly contributing to spread of resistant organisms, for i nstance, by causing diarrhoea and thereby enhancing environmental contamina tion with other gastrointestinal flora such as vancomycin-resistant enteroc occi. Thus, a consideration of C. difficile in the larger context of the wo rld-wide spread of antibiotic resistance offers useful insights that may he lp form the basis for the development of more effective control measures. ( C) 1999 The Hospital Infection Society.