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Infection with Clostridium difficile

Human infection with Clostridium difficile (CD) can take many forms. Those reading this section are probably interested in this topic because they, or perhaps a friend, may be suffering with the more severe effects of CD infection. However, there is a whole spectrum of CD infections ranging from mild forms through to life threatening clinical CD infections (1,14,25,31). These will now be described.

CD infection can exist in patients who can be clinically relatively well - eg carriers of very mildly pathogenic bacteria. Some may have recurrent mild to moderate diarrhoea resembling Irritable Bowel Syndrome (IBS) and may not be at all concerned with these symptoms. In fact they may consider themselves to be perhaps part of the normal spectrum of bowel behaviour. Still others may have recurrent bouts of severe cramps, diarrhoea with or without 'wind' and other symptoms. Unless CD is diagnosed and causes these symptoms such patients could well be labelled with a diagnosis of IBS.

Still other patients may have a condition indistinguishable from colitis, with cramps, diarrhoea, urgency, mucus and variable amounts of blood (33). At sigmoidoscopy typical inflammation is seen and may initially be diagnosed as 'idiopathic' colitis(colitis of unknown cause). This disorder can also be recurrent with red patches visible on colonoscopy in some areas of the bowel or indeed throughout the colon. This kind of colitis can respond to prednisone, Salazopyrin, Mesasal, Salofalk, Asacol (all examples of 5-ASA-containing compounds) and other anti-colitis drugs because the steroids and anti-inflammatory drugs non-specifically inhibit many types of inflammation. Furthermore, drugs such as 5-ASA compounds have their own anti-CD activity.

Lastly the most severe and even devastating CD infection can develop into 'pseudomembranous enterocolitis' (PMC) with specific type of inflammation visible at colonoscopy. It may lead to fulminant colitis, megacolon and even to death from colon perforation and peritonitis. However, these latter conditions are generally uncommon (35). Nonetheless, in recent years an epidemic form of CD has emerged with high mortality and morbidity and urgent treatment needs to be initiated especially in those of co-morbidity, the infirm and the elderly

Chronic CD infection is estimated to occur in perhaps 15-30% of those infected. In some, re-infection can occur with the same or different strain. Also, the small bowel may act as reservoir of spores, entering the colon. Risk factors for relapse are said to include the number of previous episodes, the need to use antibiotics recurrently, female sex, and older age groups. (3,34)

C difficile is acquired from contact with humans or objects harbouring these bacteria. It can be commonly acquired during hospitalization with up to 30% of those who have spent a prolonged period in hospital leaving the hospital carrying these bacteria in the bowel flora. (12,13) This is particularly so if antibiotics had been administered so disturbing the protection of the natural bowel flora. Non-hospital acquisition of CD also occurs and again a course of antibiotics may permit the growth of CD and 'awake' a clinical condition.

Human infection occurs through ingestion (via the mouth) and if the bacterium survives acid and bile on its passage into the bowel, it may be eradicated by the normal bowel flora. However, if the bowel flora is suppressed because of concomitant use of antibiotics, or if the bowel flora has a deficiency of Bacteroides bacteria(21),CD can colonize the flora and remain with the patient - generally for life. In some individuals it seems that antibiotics are not required for colonization to take place. This may be perhaps due to inadequate defence of the naturally occurring flora within the bowel. CD is a very hardy organism probably because it contains spores. Spores are unable to be eradicated by any known antibiotic. One way of eradicating spores is to autoclave the spore-containing specimen using a sterilizer. Of course a patient cannot be placed in a sterilizer. However some bacteria appear to be capable of inhibiting the growth of CD and even eradicating the spores and this characteristic has been used to develop 'bacteriotherapy' which will be described below.


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