Recurrent Clostridium difficile infection: The scope of the problem and management decisions

Clostridium difficile-associated infection is a growing problem worldwide, contributing to increased morbidity and mortality. More recently, there have been epidemics of C. difficile-associated disease in the United States and Canada with emergence of a hypervirulent NAP1/BI/027 strain (Loo et al., 2005).1 As many as 35% of patients develop recurrent C. difficile-associated disease after an initial episode. Of these patients, 50%-65% have multiple recurrences of C. difficile infection (McFarland et al., 2002).2 Still other patients develop refractory or life-threatening fulminant C. difficile colitis despite standard antibiotic treatment. In this article, we review the problem of recurrent and refractory C. difficile-associated disease, with particular emphasis on treatment options. Topics include available pharmacological treatment, fecal microbiota transplantation, and lesser-used treatment options.