matter for debate the royal colleges of surgeons of edinburgh and ireland | 325 © 2008 Surgeon 6; 6: 325-8 Health Protection Surveillance Centre, Dublin Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland Correspondence to: Dr. Fidelma Fitzpatrick, Health Protection Surveillance Centre, 25-27 Middle Gardiner Street, Dublin 1, Ireland Tel: +353 1 8765300 Fax: +353 1 8561299 Email: delma.tzpatrick@ hse.ie F. Fitzpatrick keywords: clostridium difficile, surgery Surgeon, 1 December 2008, pp. 325-8 MANAGEMENT OF CLOSTRIDIUM DIFFICILE INFECTION – MEDICAL OR SURGICAL? C. difficile infection (CDI) typically presents as diar- rhoea, abdominal cramps, fever and leucocytosis, occurring several days to up to 10 weeks after anti- biotic therapy. Pseudomembranous colitis (PMC) is the most severe manifestation and is usually a pancolitis, although a right-sided colitis is also described. Severely ill patients may have little or no diarrhoea due to dilation of the colon (toxic megacolon) and paralytic ileus that may result from a loss of colonic muscular tone. CDI-associated mortality varies with the population under study and has been reported as high as 30%, although attributable mortality is thought to be lower. 1,2 Te most common risk factors for CDI are exposure to antibiotics, advanced age and hospitalisation. Te disease is particularly linked with the use of broad-spectrum antibiotics; however, nearly all other antibiotics have been associated with CDI. 3 Te most commonly implicated are clindamycin, the broad-spectrum cephalosporins and fluroqui- nolones. While CDI is a disease predominantly of older patients, other risk factors such as hospitalisa- tion, recent gastrointestinal surgery or procedures and immunosuppressive therapy can also predis- pose to infection. Another proposed risk factor is exposure to proton pump inhibitors – it is thought that the increased gastric pH produced by these drugs leads to decreased destruction of spores. 4,5 However, this association has not been demon- strated in other studies. 6,7 In Canada, a changing pattern of CDI severity was observed from 1991 to 2003. 8 Te number of patients with compli- cated CDI (defined as having any of megacolon, perforation, colectomy, shock requiring vasopressor therapy, or death) rose significantly from around 7% in 1991-1992 to 18% in 2003. Te epidemic was largely due to the emergent hyper-virulent strain PCR ribotype 027. 9 C. difficile ribotype 027 outbreaks have been described in many European countries and recently, the first case of C. difficile ribotype 027 in Ireland was reported. 2,10 C. difficile ribotype 027 produces 23 and 16 times more toxins B and A than previously described C. difficile strains and is associated with fluoroquinolone resistance in vitro. 3 Tis editorial will discuss the clinical management of CDI, including the evidence for surgical management. Diagnosis of CDI All patients in whom a diagnosis of gastrointestinal infection is suspected should have a stool specimen sent for microbiological analysis. Te diagnosis of CDI is usually made by detection of C. difficile toxins by enzyme immunoassay (EIA). Te main advantage of these assays is rapid same day results. A wide variety of commercial EIAs exist which generally perform well with regard to specificity; however, recent studies demonstrate that they have significantly reduced sensitivity (65-85%). 11,12 Tis low sensitivity can lead to increased reporting of false negative results, subsequently presenting prob- lems with clinical diagnosis and infection control. In cases where CDI is clinically suspected and EIA results are negative, the laboratory should be informed, in order to perform culture on the speci- men. In addition, CT can be a useful adjunct. CT findings in severe CDI may include colonic thick- ening and pericolonic stranding and can predict intra-operative findings. 13-15 Management of C. difficile infection 1. Isolation of the patient and infection control precautions Prompt isolation in a single room with clinical hand washing sink and en suite facilities using standard and contract precautions is recommended for all patients with known or suspected CDI. 16 Hands should be washed before and after each contact with the patient and/or patient equipment with soap (antimicrobial or non-antimicrobial) and water. 17 None of the agents (including alcohols,