State of the Art REVIEW

Clostridioides difficile: diagnosis and treatments

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
Benoit Guery,1,2,3,6 Tatiana Galperine,1,2 Frédéric Barbut4,5,6
A BST RAC T
Clostridioides difficile (formerly Clostridium) is a major cause of healthcare
1
Infectious Diseases Service,
Department of Medicine,
associated diarrhea, and is increasingly present in the community. Historically,
University Hospital and C difficile infection was considered easy to diagnose and treat. Over the past two
University of Lausanne,
Lausanne, Switzerland decades, however, diagnostic techniques have changed in line with a greater
2
French Group of Faecal
Microbiota Transplantation
understanding of the physiopathology of C difficile infection and the use of new
3
European Study Group therapeutic molecules. The evolution of diagnosis showed there was an important
on Host and Microbiota
Interactions under- and misdiagnosis of C difficile infection, emphasizing the importance of
4
National Reference algorithms recommended by European and North American infectious diseases
Laboratory for Clostridium
difficile, Paris, France societies to obtain a reliable diagnosis. Previously, metronidazole was considered
the reference drug to treat C difficile infection, but more recently vancomycin and
5
INSERM, Faculté de
Pharmacie de Paris, Université
Paris Descartes, Paris, France
6
other newer drugs are shown to have higher cure rates. Recurrence of infection
European Study Group on
Clostridium difficile represents a key parameter in the evaluation of new drugs, and the challenge is
Correspondence to: to target the right population with the adapted therapeutic molecule. In multiple
Benoit Guery
[email protected] recurrences, fecal microbiota transplantation is recommended. New approaches,
Cite this as: BMJ 2019;366:l4609
http://dx.doi.org/10.1136/bmj.l4609
including antibodies, vaccines, and new molecules are already available or in the
Series explanation: State of the
pipeline, but more data are needed to support the inclusion of these in practice
Art Reviews are commissioned guidelines. This review aims to provide a baseline for clinicians to understand and
on the basis of their relevance
to academics and specialists stratify their choice in the diagnosis and treatment of C difficile infection based on
in the US and internationally.
For this reason they are written the most recent data available.
predominantly by US authors.

Introduction shed the microorganism in the environment, and a

Clostridioides difficile (formerly Clostridium) is growing body of evidence shows that asymptomatic
responsible for virtually all cases of pseudo­ carriers play an important role in introducing and
membranous colitis and is implicated in 10-25% maintaining transmission in the ward.10
of antibiotic associated diarrhea.1 2 It has been C difficile infection is mediated by two toxins, TcdA
recognized as a major cause of healthcare associated and TcdB, which disrupt tight junctions and destroy
diarrhea in adult patients,3 4 and is responsible for the actin cytoskeleton of enterocytes. The toxins
large outbreaks in hospital settings.5 6 Physicians induce an inflammatory response by recruiting
face two major challenges. The first is management neutrophils and mastocytes, which release cytokines,
of fulminant life threatening colitis (defined by leading to the formation of pseudomembranes.11
hypotension or shock, ileus, or megacolon)—this The toxins are encoded by two genes tcdA and tcdB
complication is rare (<5%) but associated with a which form, with three accessory genes, a 19.6 kB
high mortality (35-50%). The second challenge is pathogenicity locus. Not all patients colonized with
preventing recurrence, which occurs in 15-25% of C difficile develop C difficile infection. This suggests
cases in the two months following the initial episode.7 that other factors (immune response and intestinal
A patient presenting with a first recurrence has a microbiota balance), in addition to C difficile, are
higher risk of subsequent recurrence and may enter important in disease pathogenesis.
a cycle of multiple episodes, leading to exhaustion The metabolism of bile acids has been shown
and long courses of antimicrobial therapy. Besides to play a major role in the mechanism of C difficile
C difficile infection, asymptomatic colonization infection.12 In 1983, Wilson et al showed that primary
(defined by the presence of the microorganism in the bile acid cholic acid and its taurine conjugated
absence of C difficile infection symptoms) ranges from derivative taurocholic acid could stimulate germi­
4% to 15% of healthy adults.8 A recent study showed nation of C difficile.13 Other bile acids, including
that asymptomatic colonization by a toxigenic chenodeoxycholate, inhibit taurocholate induced
strain on admission to hospital increases the risk germination.14 Chenodeoxycholate competitively
of developing subsequent C difficile infection.9 inhibits germination at a concentration 10-fold lower
In addition, asymptomatic carriers of C difficile than cholate, and the resulting effect at homeostasis

the bmj | BMJ 2019;366:l4609 | doi: 10.1136/bmj.l4609 1

 State of the Art REVIEW

is a suppression of C difficile invasion in vivo.15 and control of C difficile infection should be holistic,
Response to biliary acids also varies across strains taking into account these factors.

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
and ribotypes.16 Moreover, it has also been shown In the US, the estimated incidence of C difficile
that antibiotic treatments, recognized as a risk factor infection in 2011 was 453 000 on the basis of data from
for C difficile infection, induce a shift in fecal bile active population and laboratory based surveillance
acid composition. An increase in primary bile acids across diverse geographic locations.4 The estimated
favours germination and a decrease in secondary annual mortality within 30 days of diagnosis was
bile acids inhibits germination, thereby promoting 29 500. In 2013, the Centers for Disease Control and
C difficile infection.17 Prevention categorized C difficile infection in the highest
priority category of antimicrobial resistance threats.
Sources and selection criteria In Europe, the estimated number of cases is
The references used in this review were identified 124 000 per year19 and C difficile was the sixth most
through PubMed and Medline searches of articles frequent microorganism responsible for healthcare
published between 1958 and 2018. Search associated infections during the 2016-17 European
terms included “bacteriophage”, “bezlotoxumab”, point prevalence study.26
“cadazolid”, “Clostridium difficile”, “Clostridioides In many countries, C difficile infection presents a
difficile”, “Clostridium infection”, “diarrhea”, “fecal substantial burden to healthcare facilities in terms of
microbiota transplantation”, “fidaxomicin”, “ileus”, morbidity and mortality,27 28 resulting in increased
“intensive care unit”, “metronidazole”, “non-toxigenic length of hospital stay and extra cost.
strains”, “pseudomembranous colitis”, “RBX2660”, C difficile infection is no longer restricted to
“ridinilazole”, “rifaximin”, “surotomycin”, “teicoplanin”, hospital settings, and is increasingly prevalent in
“tigecycline”, “tolevamer”, “toxic megacolon”, “toxoid the community. Currently, more than a quarter of
vaccine”, “vaccine”, and ‘‘vancomycin.” We prioritized all cases of C difficile infection are estimated to be
recent (after 2000) high quality reviews and community acquired,29-31 although community
randomized controlled trials in which multiple acquired infection is still under-recognized because
references would be relevant. When randomized of a lack of screening by community physicians.32 33
controlled trials were not available, we considered Epidemiological studies have shown that community
observational studies, case reports, and case series. associated C difficile infection affects groups not
For diagnostic and therapeutic algorithms, we chose previously at risk (younger patients and those
to present only scientific societies’ guidelines. In with no exposure to antibiotics in the 12 weeks
the therapeutic area, we favoured randomized before infection).29 In a prospective study of 2541
controlled trials powered in size to show a statistical patients visiting their general practitioners (GPs) for
difference on the primary parameters such as global gastrointestinal disorders, the incidence of patients
clinical cure and recurrence. When not available, we with a positive toxigenic culture and a positive cell
selected other designs and underlined the potential cytotoxicity assay was 3.27% (95% confidence
limitations to the conclusions observed. interval 2.61 to 4.03) and 1.81% (95% confidence
interval 1.33 to 2.41), respectively. GPs requested
C difficile epidemiology C difficile testing in only 12.9% of stool samples,
The incidence of C difficile infection has increased and therefore detected only 52.3% of patients who
markedly worldwide over the past two decades.4 18- had tested positive with toxigenic culture. C difficile
20
This change is assumed to be owing in part to the infection may occur out of hospital in patients
emergence and rapid dissemination of the clone PCR without traditional risk factors.
ribotype (RT) 027 but also to increased awareness
among physicians of C difficile infection, and the C difficile diagnosis
use of more sensitive methods (ie, nucleic acid A rapid and accurate diagnosis of C difficile
amplification test) for diagnosis. Other clones have infection is essential to guide treatment and to
also emerged at a regional or national level, such as prevent nosocomial transmission. Prompt diagnosis
RT 17621 in eastern Europe, RT 24422 in Australia will shorten the time to treatment initiation for
and New Zealand, RT 018 in Italy, and RT 017 in patients with a positive diagnosis and the time to
Asian countries (South Korea, China, and Japan).23 discontinuation of empirical treatment in patients
C difficile is frequently encountered in animals and with a negative result. It is also crucial to obtain
in meat such as pork, veal, and horse.24 Knetsch et reliable data with which to monitor incidence over
al reported that asymptomatic farmers and their pigs time and to compare the incidence across different
can be colonized with clonal isolates of C difficile healthcare facilities. Recent innovations and progress
RT 078, indicating that spread between animals in the field of C difficile diagnosis led the European
and humans might occur.25C difficile has also been Society of Clinical Microbiology and Infectious
found in vegetables and seafood, suggesting that Diseases (ESCMID) to update the guidelines for
C difficile infection might be a foodborne pathogen.24 C difficile infection diagnosis in 2016.
Given widespread colonization of livestock and
contamination of outdoor environments, and the Underdiagnosis
demonstration of clonal groups of C difficile shared There is considerable underdiagnosis and mis­
between humans and food animals, management diagnosis of C difficile infection in Europe, as

2 doi: 10.1136/bmj.l4609 | BMJ 2019;366:l4609 | the bmj

 State of the Art REVIEW

suggested by the prospective point prevalence EUCLID with toxigenic strains of C difficile is frequent.39 40
study.34 In this study, 7297 stool samples from 482 Testing of these infants should be limited to those

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
healthcare facilities were collected in a single day with Hirschsprung disease or other severe motility
and tested routinely at a central laboratory using a disorders or in an outbreak situation.
reference and standardized method (GDH+Toxins Repeat testing used to be common practice when
A/B). Results of local and national C difficile infection the first enzyme immunoassays for toxins with poor
testing were compared. Overall, 148 of 641 samples sensitivity came on the market in the 1980s. This
(23%) positive for C difficile were not diagnosed by practice should now be strongly discouraged because
participating laboratories owing to a lack of clinical the diagnostic gain (defined by the frequency of tests
suspicion. There were also 68 (1.5%) false negative converted from negative to positive) is very low. Of
results, resulting in misdiagnosis of C difficile infec­ note, repeat testing using a test with suboptimal
tion. Thus, a substantial burden of undetected cases specificity may generate false positive results. When
remains, which is deleterious for patients, and enzyme immunoassays for toxins are used, the
hampers control measures. diagnostic gain of a repeat sample within seven days
is 1.9%.41 For nucleic acid amplification testing,
Indications of C difficile testing—implementation of the percentage of repeat tests that turned out to be
stool rejection criteria positive within seven days of a first negative sample is
Systematic C difficile testing is recommended where between 1% and 3.2%.41-44 However, in an epidemic
diarrhea occurs in a healthcare setting, or where situation, the diagnostic gain (8.2%) is higher and
tests for common enteropathogens are negative and might be of value.45
other causes of diarrhea (eg, inflammatory colitis, Stool samples should be also taken before ini­
enteral nutrition) have been ruled out. To improve tiating a specific treatment for C difficile to avoid
laboratory test accuracy, C difficile testing is not false negative results. Sunkesula et al46 showed that
advised in patients who have received laxatives in the the cumulative number of patients converting from
past 48 hours or in those without clinical diarrhea positive to negative polymerase chain reaction was
(defined as three unformed stools in 24 hours). 7/51 (14%), 18/51 (35%), and 23/51 (45%) after
European guidelines do not currently recommend days 1, 2, and 3 treatment, respectively.
routine surveillance of C difficile colonization; Sometimes physicians order C difficile testing after
however, one quasi-experimental controlled study treatment for C difficile infection as a test of cure. This
shows that identification of colonized patients on practice is not recommended as spores and/or toxins
admission and their isolation can effectively reduce remain detectable in 7% (2/28) of patients at the end
the transmission of the disease and the incidence of treatment for C difficile infection and as many as
of C difficile infection.35 The results of this study 56% (15/27) of patients with C difficile infection have
must be reproduced in other settings before being positive stool cultures 1-4 weeks after therapy,47
considered for widespread implementation. In addi­ despite resolution of diarrhea.
tion, screening strategy (universal versus targeted Nevertheless, despite these recommendations for
screening on high risk patients) should be addressed stool selection, inappropriate testing is still frequent:
in the future. Dubberke et al reported that 36% of patients tested
At the laboratory level, only diarrheic stools for C difficile did not have diarrhea (defined as ≥3
(defined as stools taking the shape of the container diarrheal bowel movements (type 6 or 7 stool on
or stools corresponding to Bristol stool chart types the Bristol Stool Chart) in the 24 hours preceding
5 to 7) should be accepted to lessen the chance stool collection), and 19% had received a laxative.48
of obtaining positive culture results from patients Ongoing education of physicians and nurses can
merely colonized. reduce inappropriate testing.49
The stool sample should be sent to the laboratory
in a leakproof container and processed within Reference methos
two hours of collection. Daily testing (including Despite recent advances, diagnosis of C difficile
weekends) with restitution of the results within the infection remains challenging as there is no single
same day is highly recommended.36 If stool testing is assay combining high sensitivity and specificity,
delayed, stools should be stored at 4°C for maximum rapid turnaround time, and low cost. Historically,
72 hours, or frozen at −80°C. Freezing at −20°C is reference methods have been the stool cell cyto­
not recommended because it alters the toxins.37 38 toxicity neutralization assay and toxigenic culture.
Appropriate storage conditions and management of These methods detect different targets (free toxins in
stool samples are essential to avoid toxin degradation, the cytotoxicity neutralization assay, and presence of
which might result in false negative results by enzyme a strain with potential to produce toxins in toxigenic
immunoassays or stool cell cytotoxicity neutralization culture) and, therefore, results of these tests are not
assay. Rectal or perirectal swabs are inadequate for directly comparable.
toxin detection but can be used for culture or nucleic The stool cell cytotoxicity neutralization assay
acid amplification tests, more particularly in the case involves observing a cytopathic effect (rounding off
of epidemiological studies or ileus. of the cells) after inoculation of a stool filtrate on cell
C difficile testing should not be routinely performed culture. The specificity of the effect is confirmed by
in infants ≤1 year because asymptomatic colonization its neutralization assay using a toxin B antitoxin.

the bmj | BMJ 2019;366:l4609 | doi: 10.1136/bmj.l4609 3

State of the Art REVIEW

Different cell lines can be used (MCR-5, Vero, late 1980s. These now detect toxins A and B using
HeLa, Hep-2).50 This method can detect picograms chromatographic/lateral flow membrane devices.

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
of toxins. However, drawbacks include a lack of Some evidence (in older studies) shows that newer
standardization and a slow turnaround time (>48 enzyme immunoassays have improved sensitivity
hours). In addition, cell cytotoxicity neutralization compared with those detecting toxin A only;
assay is cumbersome, laborious, and requires however, the overall sensitivity remains relatively
trained personnel. Laboratories have progressively poor compared with cell cytotoxicity neutralization
abandoned this method for routine testing, although assay (from 29% to 86%) and preclude their use
it is still used as a comparator for other diagnostic as standalone tests for diagnosis of C difficile
methods that detect free toxins. infection.57 According to a systematic review of the
The toxigenic culture is a two step method, literature by Crobach et al, lateral flow membrane
which starts with the isolation of C difficile on a devices for toxins seem to a have a lower sensitivity
selective medium followed by demonstration that compared with well type enzyme immunoassays for
the isolate can produce toxins in vitro. Several toxins (0.79, 95% confidence interval 0.66 to 0.88
selective media derive from the historical cycloserine versus 0.85, 95% confidence interval 0.77 to 0.91,
cefoxitin fructose agar medium from George et al.51 respectively).57
Subsequently, taurocholate or lysozyme was added
Glutamate dehydrogenase assay
to stimulate spore germination.1 52-54 To make
Glutamate dehydrogenase is a metabolic enzyme
isolation of C difficile easier, a spore selection step,
expressed at high levels by all strains of C difficile,
based on heat or alcohol shock, can be applied
both toxigenic and non-toxigenic. A positive result
to the stool before media inoculation. Plates are
merely indicates the presence of C difficile, although
usually incubated for 48 hours (or up to seven days,
some other Clostridium species may occasionally
depending on the methods used) in an anaerobic
cross react. Glutamate dehydrogenase assays are
atmosphere at 35-37°C. Colonies of C difficile are
easy to perform and cheap; they exist as a solid
yellowish to white, circular to irregular, and flat,
phase microtiter plate format or as a lateral flow
with a ground glass appearance. The colonies
immunochromatographic membrane in a single
have a distinctive odor similar to para-cresol (or
test or a combined test with a toxin A and B.1 52 53
horse manure). In addition, C difficile colonies
The overall sensitivity of glutamate dehydrogenase
on cycloserine cefoxitin fructose agar fluoresce a
assay is 96% (86-99% compared with toxigenic
chartreuse (yellow-green) color under ultraviolet
culture). Because of the high negative predictive
light. Chromogenic agars have been developed to
value of glutamate dehydrogenase assays (ranging
facilitate the identification of C difficile colonies.55
from 98.4% to 100%), they are now often used as
However, some specific polymerase chain reaction
an initial step of a two step algorithm. Any negative
ribotypes (ie, RT 023) fail to produce black colonies
result rules out the presence of C difficile. However,
because they lack the ability to hydrolyse esculine.56
interpretation should be cautious and depends
In practice, definitive identification relies on
on the prevalence of C difficile infection: for a
biochemical characterization of isolates, or by matrix
prevalence of 10% and a glutamate dehydrogenase
assisted laser desorption ionization-time-of-flight
assay with a negative predictive value of 99%, one
mass spectrometry. Culture is essential to determine
positive stool sample out of 10 will be missed if
antimicrobial susceptibility and subsequent typing.
glutamate dehydrogenase is used as a screening
Routine antimicrobial susceptibility testing is not
method. Any positive glutamate dehydrogenase test
mandatory to guide treatment but can occasionally
result must be confirmed by a more specific method
be performed where treatment has failed clinically, or
detecting toxins.
for epidemiological purposes. Typing of C difficile is
increasingly important to improve our understanding Nucleic acid amplification tests
or C difficile infection epidemiology, to investigate Nucleic acid amplification assays became commer­
outbreaks, and to detect early the emergence of new cially available in 2009, and a variety of tests are now
hypervirulent strains. Polymerase chain reaction available. These tests use polymerase chain reaction,
ribotyping has become the reference method in loop-mediated isothermal amplification, helicase-
Europe. However, whole genome sequencing has a dependent amplification assay, and microarray
higher discriminatory power, and the availability technologies.53 58 Some platforms are designed
of next generation sequencing platforms allows for on-demand testing, whereas others are more
laboratories to use whole genome data routinely in amenable to high-throughput testing. These assays
epidemiologic investigations. detect a variety of gene targets, including conserved
Detection of the toxigenic status of the isolate can regions of tcdA, tcdB, cdt and the ∆117 deletion in
be achieved directly from colonies using nucleic acid tcdC, the latter two as surrogate markers for RT
amplification testing, cell cytotoxicity neutralization 027. Like glutamate dehydrogenase assays, nucleic
assay, or enzyme immunoassays for toxins. acid amplification assay tests have been shown
to be very sensitive in detecting toxigenic strains
Other methods (pooled sensitivity of 95%) and to display a high
Enzyme immunoassays for toxins negative predictive value for diagnosis of C difficile
The first micro well enzyme linked immunosorbent infection.57 Concerns regarding their specificity and
assays (ELISA) for toxin A became available in the positive predictive values emerged rapidly because,
4 doi: 10.1136/bmj.l4609 | BMJ 2019;366:l4609 | the bmj
 State of the Art REVIEW

in addition to cases of C difficile infection, these were subsequently confirmed by an independent

tests also detect asymptomatic carriers of toxigenic study from a single academic medical center in

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
C difficile. Another theoretical concern is the potential the US, which showed that, in patients positive
variation in tcdA and tcdB regions targeted by nucleic for toxins, the number of stools per day, the rate of
acid amplification assay test primers, which could complications, the 30 day mortality, and the level of
result in a false negative result. digestive inflammation assessed by fecal lactoferrin
Several multiplex gastrointestinal panels used were substantially higher compared with patients
for syndromic diagnostics (xTAG Gastrointestinal testing positive by nucleic acid amplification assay
Pathogen Panel, Luminex; FilmArray Gastrointestinal but negative for toxins.63 The authors concluded that
Panel, Biomérieux; Seeplex Diarrhea ACE Detection, the use of molecular tests alone is likely to lead to
Seegene) also target the C difficile toxin B gene. overdiagnosis and overtreatment.
However, the targets of these assays are seldom Nevertheless, despite the higher specificity
evaluated and compared with the gold standards for of enzyme immunoassays for toxins, detection
diagnosis of each pathogen. During a multicenter of free toxins may lack sensitivity, and enzyme
evaluation of the FilmArray Gastrointestinal Panel, immunoassays may be negative in patients with
Buss et al59 found a sensitivity and specificity for complicated C difficile infection64 or in those with
C difficile detection of 98.8% (95% confidence endoscopically proven pseudomembranous colitis.65
interval, 95.7 to 99.9) and 97.1% (95% confidence Although C difficile infection is the cause of most
interval, 96.0 to 97.9), respectively, compared with cases of pseudomembranous colitis, clinicians
toxigenic culture. should consider less common causes (ie, infectious
colitis with E coli 0157:H7, CMV, Entamoeba
Value of free toxin versus presence of toxigenic
histolytica, or treatments such as cisplatin or cyclo­
culture
sporin), especially if pseudomembranes are seen
Over the past decade, the merits of the different
on endoscopy but testing remains negative for
tests and targets (free toxin versus presence of a
C difficile.66 In a small retrospective study of 143
toxigenic strain) for diagnosis of C difficile infection
true C difficile infection patients from a single center,
have been intensively discussed. The potential for
Humphries et al did not find any difference in toxin
asymptomatic carriage of a toxigenic strain (and
enzyme immunoassay positivity between patients
toxins, to a lesser extent, as suggested by Pollock
with mild versus severe disease (49% v 58%;
et al60) added confusion to the debate. A growing
P=0.31) and concluded that the presence of stool
body of evidence shows that detection of free toxin
toxin measured by enzyme immunoassay does not
in stools best correlates with clinical symptoms and
correlate with disease severity.67
clinical outcome.
A prospective one year study showed that patients Recommended algorithm
with C difficile infection detected by nucleic acid Different algorithms have been proposed for
amplification assay test alone were less likely to diagnosis of C difficile infection. ESCMID recommends
develop a complication of the infection (ie, 30 day a two step algorithm based on a sensitive screening
mortality, colectomy, admission to intensive care, or method (nucleic acid amplification assay or gluta
readmission for recurrence) compared with C difficile mate dehydrogenase assay) followed, in the case of a
infection detected by both nucleic acid amplification positive result, by a more specific technique to detect
assay test and enzyme immunoassay/cell culture free toxins in stools (enzyme immunoassay test for
cytotoxicity assay (3% versus 39%, respectively; toxins or cytotoxicity neutralization assay)68 (fig 1). An
P<0.001). This suggested that the decrease in optional step is to perform nucleic acid amplification
complication rate could be due to earlier detection and assay for confirmation of glutamate dehydrogenase
treatment of C difficile infection or to the detection of assay-positive, toxin enzyme immunoassay-negative
C difficile carriers who develop diarrhea for another, samples. Another recommended option is to perform
unrelated reason.61 In a very large prospective a combined test detecting glutamate dehydrogenase
multicenter study from the UK that included 12 420 and toxins with an optional reflex nucleic acid
stool samples, the authors found that the presence of amplification assay test in the case of glutamate
free toxins was statistically significantly associated dehydrogenase array-positive, toxin-negative results.
with poor clinical outcomes (higher all-cause 30 Indeed, such a result can correspond to either the
day mortality rate and higher white blood cell presence of a non-toxigenic strain or the presence
count), whereas the presence of toxigenic C difficile of toxigenic strains with toxins below the detection
in feces in the absence of a positive toxin assay was threshold of enzyme immunoassay.
associated with a clinical outcome that was no worse The Infectious Diseases Society of America (IDSA)
than for samples that tested negative for C difficile.62 and Society for Healthcare Epidemiology of America
The authors concluded that the use of nucleic acid (SHEA) have published similar guidelines, with the
amplification assay testing leads to overdiagnosis exception that nucleic acid amplification assay tests
of C difficile infection. They suggested that nucleic alone can be considered if appropriate stool selec
acid amplification assays could be used as first stage tion is guaranteed (fig 1).69 This recommendation
tests to exclude the presence of C difficile, followed is supported by several studies showing that
by a more specific toxin test to identify patients nucleic acid amplification assay outperforms other
most likely to have C difficile infection. These results diagnostic test methods when applied to patients

the bmj | BMJ 2019;366:l4609 | doi: 10.1136/bmj.l4609 5

State of the Art REVIEW

who meet clinical criteria for C difficile disease (at New methods—biomarkers
least three loose or unformed stools in ≤24 hours Ultrasensitive assays that use single molecule array

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
with history of antibiotic exposure).70 71 technology60 78 79 can detect and quantify C difficile
These algorithms were proposed to combine toxins A and B over a five log range of concentrations,
sensitivity and specificity. In a setting with a starting from an analytical cut-off of approximately
C difficile infection prevalence of 5% among stool 1 pg/mL. Preliminary results indicate that single
samples, Crobach et al57 calculated the positive and molecule array assays can detect toxins in 24% more
negative predictive values of diagnosis algorithms samples with laboratory defined C difficile infection
based on nucleic acid amplification assay followed than the high performing toxin enzyme immunoassay,
by enzyme immunoassay tests for toxins. The values and therefore have the potential to improve diagnosis
were 98.5% (positive predictive value) and 98.9% of C difficile infection.80 During a clinical evaluation
(negative predictive value), whereas a standalone that included frozen stool samples from 311 patients
nucleic acid amplification assay would result in with suspected C difficile infection, Sandlund et al79
positive and negative predictive values of 45.7% and showed that the sensitivity and specificity of the
99.8%, respectively. Singulex Clarity C difficile toxins A/B assay were
These multistep algorithms also present some 97.7% (95% confidence interval, 93.0% to 99.4%)
drawbacks, however. They are more time consuming, and 100% (95% confidence interval, 95.4% to 100%),
especially when using a unitary test for screening respectively, compared with a multistep polymerase
and cell cytotoxicity neutralization assay as chain reaction and toxin testing procedure (nucleic
confirmation. Patients with a negative screening acid amplification test+enzyme immunoassay for
assay can be rapidly ruled out for C difficile infection, toxins+cell cytotoxicity neutralization assay). In
but those with a positive result must be confirmed by another study, Pollock et al60 compared the toxin
a second test, which can dramatically increase time levels of diarrheal nucleic acid amplification test-
to delivery of the final result to the physician, more positive patients with those of non-diarrheal patients
particularly when cell cytotoxicity neutralization who tested positive in nucleic acid amplification.
assay is used. These delays may negatively affect Surprisingly, they showed that toxin concentration
patient outcome.36 The use of a single test combining did not differentiate C difficile infection from
glutamate dehydrogenase assay and toxins detection asymptomatic carriage. Nevertheless, when C difficile
enables laboratories to complete the diagnosis on the infection /carrier cohorts were restricted to those with
same day. detectable toxin, respective medians were notably
Other studies have shown a correlation between different (toxin A, 874.0 v 129.7 pg/mL, P=0.021;
cycle threshold (Ct) of polymerase chain reaction, toxin B, 1317.0 v 81.7 pg/mL, P=0.003, toxins
presence of free toxins in stools, and patient A+B, 4180.7 v 349.6 pg/mL, P=0.004; Ct, 25.8 v
outcome.72-77 Senchyna et al75 estimated that an 27.7, P=0.015). No cut-off adequately distinguished
Xpert Ct cut-off of 26.4 had a negative predictive between patients with C difficile infection and those
value of 97.1% for excluding the presence of toxin who were carriers of C difficile. In conclusion, single
in stool. Crobach et al showed that the accuracy of molecule array technology for detection of C difficile
Ct values of their home-made polymerase chain toxins is ultrasensitive and has the potential to be
reaction to predict toxin A/B enzyme immunoassay a standalone test to replace the multistep testing
results varies between 78.9% and 80.5%.76 Dionne algorithms currently recommended for C difficile
et al72 have shown that Ct of polymerase chain diagnosis.
reaction is lower in patients with a positive enzyme Lactoferrin (an iron binding glycoprotein)
immunoassay for toxins (mean Ct=28.4) compared and calprotectin (a calcium binding protein) are
with patients negative for toxins (mean Ct=39.1). In two proteins derived from polymorphonuclear
another study where patients with C difficile infection neutrophils, which are released by the gastro­
were stratified according to the severity defined intestinal tract in response to infection and mucosal
by the IDSA/SHEA criteria, Jazmati et al73 found a inflammation.81 These markers are used routinely
lower Ct in patients with severe C difficile infection to monitor levels of inflammation in patients with
compared with patients with mild to moderate inflammatory bowel disease. As C difficile infection
disease. Reigadas et al74 showed that low toxin B Ct is histologically characterized by an infiltration of
values from samples collected at the initial moment neutrophils, fecal lactoferrin or calprotectin may
of diagnosis appear to be a strong marker for poor represent potential biomarkers for disease activity.
outcome. Many studies have shown that patients with
The second limitation of these diagnostic C difficile infection have higher lactoferrin and
algorithms is that a sensitive and rapid assay for calprotectin levels82-86 compared with diarrheal
detection of toxin does not exist, and therefore patients testing negative for C difficile and with non-
among patients suspected to have C difficile infection diarrheal controls. These two markers were found
and harboring a toxigenic strain (nucleic acid to be highly correlated with each other, which is not
amplification-positive), up to one third do not have surprising considering their common cellular origin.
any detectable toxin. In this case, it seems difficult However, these studies also reported a great variability
to discriminate between true C difficile infection or of fecal lactoferrin and calprotectin levels, with an
carriage of a toxigenic strain. overlap between patients with C difficile infection and

6 doi: 10.1136/bmj.l4609 | BMJ 2019;366:l4609 | the bmj

 State of the Art REVIEW

European Society for Clinical Microbiology and Infectious Diseases recommended diagnostic algorithm for C.diƸcile infection (2016)

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
CDI is likely to
– be absent Clinical evaluation: NAAT or
CDI or carriage of TC (in case
Highly sensitive test – (toxigenic) rst test
NAAT or GDH EIA
C. diƸcile is possible was a GDH)
Highly specic test
+ Toxin A/B EIA
CDI is likely
+ to be present
Multiple step
algorithm
CDI is likely
–/– to be absent

EIA for GDH CDI is likely

and toxin A/B
+/+ to be present CDI is likely to
– be absent

Clinical evaluation:
+/– NAAT
CDI or carriage of
+ (toxigenic)
C. diƸcile is possible

Infectious Diseases Society of America recommended diagnostic algorithm for C.diƸcile infection (2018)

Clinician and laboratory Multiple step

personnel agree to not
No algorithm*
submit stool specimens on
patients receiving laxatives,
and to submit stool
specimens for patients only
Multiple step CDI is likely to
with unexplained or new
algorithm* – be absent
onset diarrhea with Ɲ 3
unformed stools in 24h for
testing of CDI Yes
NAAT CDI is likely
+ to be present
Optional
* As recommended by the ESCMID

Fig 1 | Algorithms for the diagnosis of C difficile infection recommended by the European Society of Clinical Microbiology and Infectious Diseases
(ESCMID) and the Infectious Diseases Society of America (IDSA). CDI, C difficile infection; NAAT, nucleic acid amplification test; GDH EIA, glutamate
dehydrogenase enzyme immunoassay; TC, toxigenic culture.

controls.87 88 This observation reduces the predictive experimental work performed on hamsters showed
accuracy of both markers for C difficile infection and the efficacy of metronidazole and vancomycin.90
makes it difficult to determine an optimal cut-off Thirteen patients with antibiotic induced colitis were
value.82 In summary, the sensitivity and specificity of given vancomycin (500 mg four times daily) and none
lactoferrin and calprotectin are too low to recommend experienced a recurrence during a follow-up ranging
their routine use for screening of patients. from one to six months.91 The choice of vancomycin
over metronidazole in this initial work was based
Treatment on its minimal absorption after oral administration,
Antibiotics it reaching high colonic concentrations (measured
Metronidazole and vancomycin at a mean level of 3.100 mg/g of stool), and the
When C difficile infection was described in 1893, optimal results in the hamster given vancomycin
no specific treatment was available.89 In 1979, an over metronidazole. Eleven of 13 patients presented

the bmj | BMJ 2019;366:l4609 | doi: 10.1136/bmj.l4609 7

State of the Art REVIEW

with a severe infection according to definitions from more importantly, clinical success of metronidazole
IDSA/SHEA, with a leucocytosis between 17 000 was also inferior to vancomycin (72.7% v 81.1%,

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
and 45 000 cells/mm3. An editorial suggested that, P=0.02). A retrospective propensity matched cohort
although vancomycin was highly efficient, it may be study evaluated the risk of recurrence and all
advisable to lower the dose to limit damage to the gut cause 30 day mortality among patients receiving
microbiota.92 metronidazole or vancomycin.99 One drawback of
Measurement of fecal metronidazole and hydro­ this study, besides the retrospective design, is the
xymetronidazole was performed in nine patients definition of recurrence which is restricted to another
with C difficile infection.93 The authors showed that positive laboratory test result for C difficile more than
concentration of these two molecules decreased 14 days, but fewer than 56 days after the initial
substantially with recovery. The concentrations diagnosis date. No clinical parameter was included,
obtained were, proportional to the minimum making the results on this parameter not relevant.
inhibitory concentration, lower than vancomycin Nevertheless, the risk of 30 day mortality was
(usually below 20 μg/g of stool for an minimum statistically significantly reduced among patients
inhibitory concentration ranging between 0.25 and receiving vancomycin. Globally, these data confirm
1 mg/L). that metronidazole has a lower efficacy compared
The first prospective randomized trial comparing with vancomycin and support the use of vancomycin
metronidazole with vancomycin analyzed 52 over metronidazole in C difficile infection. To optimize
patients in the vancomycin group and 42 in the vancomycin treatment evaluated in recurrent
metronidazole group.94 The main result of this study C difficile infection, it might be possible to use a pulsed
was that these drugs had equivalent efficacy and or tapered regimen of vancomycin. Evidence for this
recurrence rate. However, this trial was not blinded, approach includes observational studies showing
recurrence was evaluated over a three week period, recurrence rates ranging from 31% to 6%100-102 and
and most importantly, according to the number one randomized trial that included 12 patients,
of patients analyzed, this study was not powered where the recurrence rate reached 41.7%.103
to show a difference in efficacy. The second trial,
published 10 years later, presents exactly the same Fidaxomicin
limitations comparing vancomycin, teicoplanin, Fidaxomicin was discovered in the late 1970s and
metronidazole, and fucidic acid.95 This trial was also was developed by pharmaceutical companies under
unblinded, included a limited number of patients different names between the late 1980s and mid-
(31 with vancomycin and 31 with metronidazole), 2000s.104 105 Fidaxomicin is a narrow spectrum
and the follow-up period was limited to 30 days after antibiotic with activity against Gram positive
discontinuation of therapy. From these two studies, aerobes and anaerobes. The drug is not active
metronidazole was nevertheless considered to be against Gram negative pathogens, thus preserves
the drug of choice in C difficile infection because it the normal gastrointestinal microbiota. Fidaxomicin
was less expensive and was not associated with inhibits bacterial protein synthesis via transcription
the potential increase in vancomycin resistant inhibition.106 Two phase 3 trials with the same
organisms.96 Two later studies changed these design—one in patients in the US and Canada (629
conclusions. A randomized, prospective, double patients),107 and one in Europe (535 patients)108—
blind, placebo controlled trial with 172 patients provided consistent and reproducible results
compared vancomycin with metronidazole.97 The comparing fidaxomicin with vancomycin in C difficile
patients were stratified according to disease severity infection. Rates of clinical cure with fidaxomicin
and were followed for 21 days. The overall cure rate were non-inferior to those after treatment with
was 84% in the metronidazole group and 97% in vancomycin, but in both studies, fidaxomicin was
the vancomycin group (P=0.006). No difference was associated with a significantly lower rate of recurrence
observed for patients with mild disease, but in severe (15.4% v 25.3%,108 12.7% v 26.9%107). As expected
forms, treatment success was seen in 76% and 97% from the earlier studies, the efficacy of fidaxomicin
of the cases for metronidazole and vancomycin, on recurrence (compared with vancomycin) is linked
respectively (P=0.02). However, the definition to preservation of gut microbiota. In fact, analysis
of severity was based on a score not previously of a subset of 89 patients from the phase 3 trial108
validated and the follow-up for a recurrence was showed that major components of the microbiome
limited to 21 days. Nevertheless, this study showed persisted after fidaxomicin administration, whereas
the superiority of vancomycin over metronidazole vancomycin was associated with a further 2-4 log10
for patients with severe C difficile infection. A further reduction in colony forming units of Bacteroidetes/
study comparing metronidazole and vancomycin Prevotella group organisms.109 Among the other
was designed to evaluate the efficacy of tolevamer, potential mechanisms, a reduction in toxin A and
a non-antibiotic, toxin binding polymer.98 The study B production could also be involved.110 Finally,
authors pooled and analyzed the results of two fidaxomicin was also shown to improve control of
multinational randomized controlled trials, where environmental contamination with C difficile. After
563 patients were treated with tolevamer, 289 with analyzing surfaces in the rooms of 134 patients treated
metronidazole, and 266 with vancomycin. Tolevamer with fidaxomicin, metronidazole, or vancomycin,111
was inferior to metronidazole and vancomycin, but the authors showed that fidaxomicin was associated

8 doi: 10.1136/bmj.l4609 | BMJ 2019;366:l4609 | the bmj

 State of the Art REVIEW

with reduced environmental contamination with in clinical cure or recurrence rate.119 If tigecycline is
C difficile (57.6% v 36.8%, P=0.02). used to treat severe infections, it should be considered

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
One method proposed to improve the efficacy a substitute to metronidazole as adjunctive therapy
of fidaxomicin was suggested by using an in vitro to vancomycin.
human gut model.112 A randomized, controlled,
Combination of molecules
open label, superiority study enrolled 364 patients
Use of combined molecules is recommended in
to test the hypothesis that a pulsed regimen could
complicated forms of C difficile infection,69 120
improve the rate of recurrences.113 Patients received
although evidence for this is limited. A single center
fidaxomicin 200 mg twice daily on days 1-5, then
retrospective observational comparative study
once daily on alternate days on days 7-25 (extended
evaluated 88 patients in the intensive care unit with
pulsed fidaxomicin), or commercially available oral
C difficile infection.121 The results showed a statisti­
vancomycin 125 mg capsules four times daily on
cal improvement of survival: mortality was 36.4%
days 1-10. The primary endpoint was sustained
and 15.9% in the monotherapy and combination
clinical cure 30 days after the end of treatment. The
groups, respectively. Oral vancomycin may play a
results showed that 70% of patients with extended
key role in the association: in a mouse model, the
pulsed fidaxomicin achieved sustained clinical
addition of metronidazole to vancomycin improved
cure, compared with 59% of patients receiving
clinical outcome.122 In a retrospective analysis on
vancomycin. This study provided the lowest
the efficacy of intracolonic vancomycin, patients
recurrence rate observed in a randomized clinical
treated with intracolonic vancomycin and standard
trial for C difficile infection. The greatest criticism
treatment compared with standard treatment alone
of the study relates to the choice of comparators:
had comparable mortality rates, but severity score,
extended fidaxomicin versus vancomycin. Compa­
transfer to the intensive care unit, and percentage of
ring extended pulsed fidaxomicin with a routine
toxic megacolon were higher in the group receiving
10 day regimen of fidaxomicin may have given
intracolonic vancomycin.123 A randomized study in
the results more relevance. From these studies,
this subset of patients is needed.
fidaxomicin seems to represent a drug of choice in
C difficile infection, although one report describes Fecal microbiota transplantation
the first strain of C difficile to have markedly reduced Efficacy
susceptibility to the treatment.114 Fecal microbiota transplantation is proposed to treat
Teicoplanin recurrent C difficile infection. It was initially descri­
Teicoplanin is a glycopeptide antibiotic that is active bed in 1958 in the treatment of pseudomembranous
against C difficile. Few studies on its efficacy have enterocolitis.124 The first randomized study was
been performed. A prospective randomized study published in 2013 and studied the effect of duodenal
comparing several drugs showed that clinical cure infusion, through a nasoduodenal tube, of donor
was obtained in 96% of cases, which is similar to feces in patients with recurrent C difficile infection.125
vancomycin.95 The number of recurrences was, The study was stopped after an interim analysis. Of
however, lower (7% v 16%) but the difference was the 16 patients in the infusion group, 13/16 had
not statistically significant; however, the study was resolution of diarrhea and three patients received a
not powered to answer this question. A prospective second infusion, after which symptoms resolved in
observational study compared vancomycin with two, to reach an overall cure rate of 93.8% The control
teicoplanin in patients with severe infection.115 groups with vancomycin alone or vancomycin with
Treatment with teicoplanin resulted in higher bowel lavage were cured in 31% and 23% of cases,
clinical cure rate (90.7% versus 79.4%) and fewer respectively. This study concluded that infusion
recurrences (9.3% v 34.3%), both percentages of donor feces was substantially more effective for
reaching statistical significance. the treatment of recurrent C difficile infection than
using vancomycin. A potential limitation of this
Tigecycline study concerning the efficacy of vancomycin treated
Tigecycline is a glycylcycline class antibiotic which patients would be that only one trial of vancomycin
has been proposed for treating severe cases of was allowed, whereas it might have been reasonable
C difficile infection.116 A retrospective observational to propose in these recurrent forms either pulsed or
cohort study compared patients receiving tigecycline tapered vancomycin regimens. A comparable study
monotherapy with patients given standard was performed via colonoscopy, also stopped after
treatment.117 Patients treated with tigecycline had a a one-year interim analysis, with 20 patients.126
statistically significantly better clinical cure (34/45, Eighteen of the 20 patients treated with fecal
75.6% v 24/45, 53.3%; P=0.02), less complicated microbiota transplantation exhibited resolution of C
disease course, and less C difficile infection difficile infection compared with 5/19 of the patients
sepsis compared with patients receiving standard treated with vancomycin. This was confirmed in
therapy. These data support the use of tigecycline several other randomized trials.
in complicated and severe C difficile infection. Two Since these initial trials, results have been published
retrospective studies confirm the safety of the drug from seven randomized clinical trials, including open
in severely infected patients118 but failed to show label randomized trials with no controlled group or
an improvement compared with standard therapy placebo, using fecal suspension.103 127-132 Overall

the bmj | BMJ 2019;366:l4609 | doi: 10.1136/bmj.l4609 9

State of the Art REVIEW

efficacy rates range between 80% and 94% after one transplantation for severe C difficile infection refra­
or multiple fecal microbiota transplants in all clinical ctory to antibiotic treatment.140 All patients had a

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
trials but one.103 In this single center, open label, clinical response to the procedure. Fecal microbiota
randomized controlled trial, the authors compared transplantation is not yet recommended in severe
the effectiveness of 14 days of oral vancomycin C difficile infection and randomized clinical trials are
followed by a single fecal microbiota transplantation needed to evaluate its use in this specific indication.
by enema with a 6 week taper of oral vancomycin in Fecal microbiota transplantation has been proposed
patients experiencing acute episodes of recurrent in complicated forms of C difficile infection as an
C difficile infection. Seven out of 16 patients alternative to surgery.141-143 Evidence for use of
were cured with fecal microbiota transplantation fecal microbiota transplantation remains limited,
compared with 7/12 with tapered vancomycin. In and this option should be considered as part of a
this study, which was stopped at the interim analysis, multidisciplinary approach.
fecal microbiota transplantation was performed by First episode of C difficile infection—Using fecal
single enema, whereas studies by Cammarota and microbiota transplantation in a first episode of
Lee126 130 showed that the efficacy increased with C difficile infection has also been evaluated. In
multiple infusions. Moreover, 6/16 patients did not a randomized clinical trial that compared oral
retain at least 80% of the enema. In other words, vancomycin with first line fecal microbiota trans­
these patients did not receive an optimal treatment plantation, symptoms resolved in 8/9 patients treated
with fecal microbiota transplantation.133 with vancomycin versus 4/7 in the fecal microbiota
Two recent meta analyses on randomized controlled transplantation arm.144 A proof of concept trial
trials found consistent conclusions that enema was randomly assigned 21 patients to oral metronidazole
less efficient than oral or colonoscopy administration or fecal microbiota transplantation by enema.145
of fecal microbiota transplantation, and had Evaluation was performed at days 4, 35, and 70. Seven
efficacy equivalent to capsules or colonoscopy. patients in the transplantation group responded to
No difference was seen between fresh and frozen treatment (78%; 95% confidence interval 40 to 97),
stool.134 135 In a systematic review published by Tariq as compared with five in the metronidazole group
et al, the authors concluded that fecal microbiota (45%; 95% confidence interval 17 to 77) (P=0.20),
transplantation was associated with a lower cure suggesting that fecal microbiota transplantation could
rate in randomized controlled trials compared be an option in a first episode. Transplantation in this
with open label and observational studies,135 and setting is challenging, however, because the long term
attributed this to the heterogeneity of the recurrence effects have yet to be explored.
definition, but also to the inclusion of microbiota Immunocompromised patients—A multicenter
based drugs (SER-109), or administration by enema. retrospective study included 75 adults and 5 chil­
A systematic review including 18 observational dren146 with immunosuppression related to solid
studies with 611 patients showed a primary cure organ transplant, oncologic conditions, HIV/AIDS,
rate of 91.2% (95% confidence interval 87.6% to and immunosuppressive therapy. The overall cure
94.8%).136 rate reached 89%. None of these high risk pati­
Data show that frozen stools are as efficient as ents developed related infectious complications.
fresh stools,130 137 138 and lyophilized products Similarly, several reports show a good efficacy of
have a lower efficacy.131 An unblinded randomized fecal microbiota transplantation in severe and/
trial comparing fecal microbiota transplantation or complicated forms of C difficile infection in the
by capsule and by colonoscopy129 found that intensive care unit.141 147-151 The largest cohort is
prevention of recurrent C difficile infection after a retrospective and described the evolution of 111
single treatment was achieved in 96.2% in both patients: 66 in the fecal microbiota transplantation
capsule and colonoscopy groups. Fecal microbiota group and 45 in the non-fecal microbiota trans­
transplantation via oral capsules was not inferior to plantation group.152 The authors showed that fecal
delivery by colonoscopy over a 12 week period. microbiota transplantation improves survival in
Fecal microbiota transplantation is therefore a severe cases, concluding that early fecal microbiota
highly effective treatment in recurrent C difficile transplantation reduces mortality and should be
infection, although the methods to deliver it are proposed as a first line treatment for severe C difficile
varied. infection; however, no formal society guidelines
recommend use of fecal microbiota transplantation
New indications in C difficile infection
in severe C difficile infection. More data are required
Severe and complicated C difficile infection—No
to confirm a clinical benefit.
consensus exists on the definition of severity, which
varies among scientific societies69 120 and clinical Mechanism of action
trials.97 107 108 Ianiro et al compared single and The mechanism explaining the high efficacy of
multiple infusions in severe refractory C difficile fecal microbiota transplantation is multifactorial
infection.139 This randomized clinical trial included and not yet completely understood. Restoration of
56 patients and showed that multiple fecal infusions gut microbiota diversity is probably an important
were more effective than a single transplantation factor, and an association between clinical cure
(respectively 100% v 75% cure rate). Another study and increased diversity was shown in a pivotal
reported four patients treated with fecal microbiota trial.125 Staley et al showed that complete microbiota

10 doi: 10.1136/bmj.l4609 | BMJ 2019;366:l4609 | the bmj

 State of the Art REVIEW

engraftment was not essential for recovery following with a direct effect on C difficile germination, for
fecal microbiota transplantation.153 The authors example before antibiotic treatment. A proof of

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
underline the key role of bacteria associated with concept study was performed with a patient with
secondary bile acid metabolism, which were recurrent C difficile infection ileal pouchitis treated
associated with an increased resistance to infection. with ursodeoxycholic acid.165 The patient remained
Consistent with these data, analysis of patients’ free of infection for more than 10 months after
feces before and after fecal microbiota transplan­ initiation of treatment. A phase 4 clinical trial under
tation showed that feces before fecal microbiota way to measure the efficacy of ursodeoxycholic
transplantation induced germination, and after acid supplementation following C difficile infection
fecal microbiota transplantation inhibited vegetative (NCT02748616). The primary outcome is the return
growth.154 A study evaluating 10 patients after to a normal pattern of fecal bile acids.
fecal microbiota transplantation showed consistent
Other drugs
results, with a restoration of secondary bile acid levels
Several molecules are being tested in C difficile
in all patients receiving transplants.155 Finally, if the
infection: CRS3123 inhibits bacterial methionyl-
structure of the microbiota is important, function
tRNA synthetase,166 and LFF571 blocks protein
probably counts also.156 The efficacy of sterile fecal
synthesis.167 Two toxin binders, calcium alumino­
filtrate also suggests that bacterial components,
silicate antidiarrheal (NCT01570634) and GT160-
bacteriophages, or active metabolites play a major
246 (NCT00466635), need more clinical data, and
role in efficacy and should be further evaluated.157 158
further research is needed. Finally, three drugs have
Donor selection been evaluated in C difficile infection: cadazolid,168 169
One challenge to implementing fecal microbiota tolevamer,98 and surotomycin.170 but the clinical
transplantation is how to obtain a validated screened results did not show any difference against the
donor.159 Screening practices vary between countries, comparator and development was stopped.
and several guidelines are now published.160 161 The
US Food and Drug Administration issued a safety alert Bacteriophage
in June 2019 following the death of a patient who Phage tail-like particles have been assessed in vitro
had received transmission of multi-drug resistant and have shown capability to eradicate C difficile.171
organisms via fecal microbiota transplantation.162 To date, no clinical trials are recorded.
However, analysis of this event was complicated Non-toxigenic strains
because screening of donors for multi-drug resistant Spores of non-toxigenic C difficile are protective
organisms is normally always performed, and a link against toxigenic strains.172 A case report showed the
between death and fecal microbiota transplantation, potential for non-toxigenic C difficile in preventing
as well as the cause of death, was not reported. It recurrence of C difficile infection.173 An oral sus­
is therefore difficult to perform a comprehensive pension was evaluated for tolerance in healthy
analysis of this serious adverse event. subjects showing the expected gastrointestinal
To conclude, fecal microbiota transplantation is an colonization.174 A phase 2 randomized placebo con­
efficient treatment for recurrent C difficile infection, trolled clinical trial with 173 patients treated with
and potentially for other forms of the disease, such metronidazole or vancomycin showed that non-
as severe or complicated C difficile infection. The toxigenic C difficile colonized the gastrointestinal tract
mechanisms associated with its success are not yet and substantially reduced recurrence of C difficile
completely understood and questions are pending infection from 30% in the placebo group to 5% in the
regarding alternative methods (microbiota based patients receiving 107 spores/day for seven days.175
preparations, sterile filtrate) and more importantly, To summarise, five drugs are currently available to
long term safety. treat C difficile infection: metronidazole, vancomycin,
fidaxomicin, tigecycline, and teicoplanin. A systematic
Emerging treatments
review and network meta-analysis screened 23 004
Ridinilazole
studies and selected 24 trials including a total of 5361
Ridinilazole is a novel antibiotic with a targeted
patients and compared treatments for non-multiply
activity on C difficile. A phase 1 study showed a positive
recurrent infections with C difficile.176 For sustained
safety profile, supporting its clinical development.163
clinical cure, fidaxomicin and teicoplanin were
A phase 2 trial compared ridinilazole with van­
better than vancomycin. Vancomycin, fidaxomicin,
comycin in 100 patients, the primary endpoint
teicoplanin, ridinilazole, and surotomycin were all
being a sustained clinical response.164 Ridinilazole
better than metronidazole. A Cochrane analysis was
was found superior to vancomycin, the sustained
consistent with those conclusions: in mild infections,
clinical response reaching 66.7% in the treatment
vancomycin is superior to metronidazole and
group compared with 42.4% in patients treated with
fidaxomicin to vancomycin.177
vancomycin. Two phase 3 studies are due to start in
2019 (NCT03595553 and NCT03595566).
Prevention
Ursodeoxycholic acid Drugs
Bile acids play a key role in C difficile infection. Some Rifaximin
compounds are potent inhibitors of germination.14 A Rifaximin is a non-absorbable rifamycin antibiotic
stable inhibitor could represent a useful prophylaxis that has been tested in a randomized double blind
the bmj | BMJ 2019;366:l4609 | doi: 10.1136/bmj.l4609 11
State of the Art REVIEW

study to prevent recurrence after completion of Two phase 3 clinical trials (MODIFY I and MODIFY
standard antibiotic therapy (generally with metro­ II) evaluated the two antibodies’ ability to reduce

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
nidazole or vancomycin).178 In the study, recurrence recurrence in 2655 patients. In the trials, patients
of C difficile infection decreased from 31% in the received standard oral antibiotics for primary or
placebo group to 15% after rifaximin. A placebo recurrent C difficile infection, plus an infusion of
controlled trial confirmed these results, with a either bezlotoxumab, actoxumab plus bezlotoxumab,
decrease of recurrence at 12 weeks from 29.5% to or placebo.188 Actoxumab alone was administered in
15.9%.179 In another trial, where the drug was used MODIFY I but discontinued after interim analysis.
to prevent encephalopathy in patients with cirrhosis, Addition of actoxumab did not improve efficacy;
rifaximin was associated with an outbreak of however, bezlotoxumab alone was associated
C difficile infection with rifaximin resistant strains of with a substantial reduction in recurrent infection
C difficile.180 To date, no trials have been registered to compared with placebo (17% v 28%). No difference
evaluate rifaximin in C difficile infection. was seen in the rates of clinical cure between
bezlotoxumab and placebo (80%), and sustained
Probiotics
clinical cure was 64% for bezlotoxumab and 54% for
Probiotics are live microorganisms administered
placebo. Rates of adverse event were similar among
to restore a dysbiotic environment and potentially
prevent C difficile infection. Bio-K is a probiotic the treatment groups. A phase 3 trial in children is
associated with three species of Lactobacillus. A currently recruiting to evaluate safety, tolerability,
phase 3 trial, randomized and double blinded, and efficacy of bezlotoxumab (NTC03182907).
showed that Bio-K prophylaxis during antibiotic Vaccines
treatment was associated with a lower incidence of Two vaccines are under evaluation.
antibiotic or C difficile associated diarrhea.181 Two A formalin inactivated toxoid based vaccine is
other probiotics with different associations were currently the most advanced. Formulation is by
clinically tested: VSL#3 and Howaru Restore. VSL#3 inactivation of toxins A and B to produce toxoids A
was tested in a multicenter randomized double and B, which elicit a protective immune response.
blind study in patients exposed to an antibiotic A phase 1 study of C difficile toxoid vaccine was
course.182 The results showed a decrease in cases performed in healthy volunteers.189 Vaccination was
of antibiotic associated diarrhea, but no cases of well tolerated and more than 90% of the volunteers
C difficile infection were reported. Howaru Restore developed a strong serum antibody response to both
was also evaluated in a randomized trial at different toxins. The phase 2 study found that a high dose
dosages.183 The results showed a decrease in (100 μg) with adjuvant treatment administered
C difficile associated diarrhea in the probiotic group. at 0, 7, and 30 days elicited the best immune
Microbiota based drugs response through day 180.190 A phase 3 study was
Microbiota based treatments, which include RBX2660 started (NCT00772343), but was interrupted after
and SER-109, are suspensions of microbiota prepared a planned interim analysis. The Independent Data
from human stool that have a mechanism similar Monitoring Committee for the phase 3 Cdiffense
to fecal microbiota transplantation. A randomized clinical trial program concluded that the probability
placebo controlled trial of RBX2660 showed that the trial would meet its primary objective was
superiority, with an overall efficacy of 88.8%.184 SER- too low.
109 is an encapsulated mixture of purified Firmicutes Another phase 1 study evaluated VLA84, a
spores. A phase 2 trial of the drug that included recombinant fusion protein with relevant epitopes of
30 patients showed that SER-109 successfully toxins A and B, as a vaccine candidate in a healthy
prevented C difficile infection.185 Two phase 3 trials population and in older adults.191 VLA84 was well
(ECOSPOR III and IV) in the treatment of recurrent tolerated and induced high antibody titer against
C difficile infection are recruiting (NCT03183141, toxins A and B in both populations. Comparable
NCT03183128). Another drug from the same results were found with another formulation.192
company, SER-262, is being tested in a phase 1 study No information is available on a potential phase 3,
(NCT02830542). planned or ongoing.

Antibodies and vaccines Emerging treatments

Antibodies Beta-lactamase—Preserving the gut microbiota
Fully human monoclonal antibodies targeting C during systemic β-lactam treatment can be achieved
difficile toxins A and B have been developed and using non-absorbable β-lactamases. SYN-004 is
showed a statistically significant efficacy in a hamster a recombinant β-lactamase designed to reduce
model.186 A randomized, double blind, placebo the effect of systemic β-lactam. Two phase 2
controlled study evaluated these two monoclonal trials confirmed that the molecule fully degraded
antibodies (actoxumab for C difficile toxin A, and ceftriaxone that had entered the gut after systemic
bezlotoxumab for toxin B) in 200 patients who administration.193
had initially been treated with metronidazole DAV132—is an activated charcoal based product
or vancomycin.187 The rate of recurrence was that irreversibly captures antibiotics. As with
substantially lower among patients treated with the β-lactamase, the goal is to inactivate the gut dysbiosis
antibodies (7% v 25%). induced by systemic antibiotics.194

12 doi: 10.1136/bmj.l4609 | BMJ 2019;366:l4609 | the bmj

 State of the Art REVIEW

Lactoferrin—has been proposed prophylactically (>15×109/L), decreased blood albumin (<30 g/L),
in long term care for patients who require broad and rise in serum creatinine level (≥133 μmol or ≥1.5

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
spectrum antibiotics (NCT00377078). times the pre-morbid level). A comparable approach
Probiotics—Several probiotics are currently being was proposed for recurrence with four additional
tested, specifically Lactobacillus reuteri. Two phase factors with a high level of recommendation: age ≥65
3 trials have recently completed (NCT02127814, years, continued use of antibiotics (not for C difficile
NCT01295918) and a randomized trial is proposed infection), comorbidity, and a previous history
but is not yet recruiting (NCT03647995). of C difficile infection. In this recommendation,
Polyclonal oral antibodies—are being evaluated metronidazole is still proposed for non-severe
in phase 2/3 trials, and include hyperimmune C difficile infection. For severe infection, or in patients
bovine colostrum (NTC00747071) and whey protein at risk of developing severe C difficile infection,
concentrate 40% (NTC001177775). Results are not vancomycin is the first choice. For a first recurrence,
yet available. or for patients at risk of recurrence, both vancomycin
and fidaxomicin are proposed as first line therapy.
Vaccines
Finally, for multiple recurrent C difficile infection,
• A DNA vaccine is being developed with fecal microbiota transplantation is recommended.
encouraging results from animal models195 196 In 2018 IDSA/SHEA updated recommendations
• Genetically modified toxins A and B were on treatment of adults.69 In non-severe C difficile
recently tested in a phase 1 trial197 and a phase infection, both vancomycin and fidaxomicin were
2 trial (NCT02561195). A phase 3 trial is proposed, and metronidazole was downgraded to
recruiting (NCT03090191) an alternative treatment if the two other agents are
• CDVAX is an oral vaccine that uses spores from unavailable. Both vancomycin and fidaxomicin are
a genetically modified bacterium. A phase 1 trial recommended in severe forms of C difficile infection,
was terminated and results are not yet available and fecal microbiota transplantation remains the first
(NCT02991417). choice in multiple recurrences of C difficile infection
where appropriate antibiotic treatments have failed
International guidelines—a critical view (for at least two previous recurrences).
A turning point in the treatment of C difficile Bezlotoxumab is not included in any algorithm
occurred in 2014 with the publication of the for the treatment of C difficile infection (the study
European treatment guidance,120 which included results pertaining to treatment with bezlotoxumab
new definitions for severity and the identification of were released after the most recent IDSA/SHEA
subgroups with an increased risk of complications guidelines). With the data currently available, it
and an increased risk of recurrence. Before this would be difficult to include the antibody in any
recommendation, IDSA/SHEA based the definition guideline, most importantly because the population
of severity on leucocytosis and the serum creatinine for whom bezlotoxumab would be most appropriate is
level.87 ESCMID defines severity with signs and patients with a high risk of recurrence. Such patients
symptoms from clinical evaluation, laboratory are likely to be immunosuppressed (hematology,
investigations, colonoscopy, and imaging (table 1), biotherapy, cancer) and exposed to broad spectrum
and defines prognostic factors to identify patients antibiotics. We need clinical studies to evaluate the
with an increased risk of developing severe C difficile efficacy of bezlotoxumab in this subset of patients,
infection. Four factors were classified with a strong and obtaining an adequate population to prescribe
recommendation: age ≥65, marked leucocytosis monoclonal antibodies needs development.

Table 1 | Severity criteria for C difficile infection, defined by ESCMID

Category Signs/symptoms
Physical examination Fever (core body temperature >38.5°C)
Rigors (uncontrollable shaking and a feeling of cold followed by a rise in body temperature)
Haemodynamic instability including signs of distributive shock
Respiratory failure requiring mechanical ventilation
Signs and symptoms of peritonitis
Signs and symptoms of colonic ileus. Mixture of blood with stools is rare in C. difficile infection and the correlation
with severity of disease is uncertain
Laboratory Marked leucocytosis (leucocyte count >15 9 109/L)
investigations Marked left shift (band neutrophils >20% of leucocytes)
Rise in serum creatinine (>50% above baseline)
Elevated serum lactate (≥5 mM)
Markedly reduced serum albumin (<30 g/L)
Colonoscopy or Pseudomembranous colitis
sigmoidoscopy Insufficient data is available on the correlation of endoscopic findings compatible with C. difficile infection
(eg, edema, erythema, friability, and ulceration) and the severity of disease
Imaging Distension of large intestine (>6 cm in transverse width of colon)
Colonic wall thickening, including low-attenuation mural thickening
Pericolonic fat stranding
Ascites not explained by other causes. The correlation of haustral or mucosal thickening, including thumbprinting,
pseudopolyps and plaques, with severity of disease is unclear

the bmj | BMJ 2019;366:l4609 | doi: 10.1136/bmj.l4609 13

State of the Art REVIEW

Conclusion and refinement of the definitions unravelling the

The diagnosis of C difficile infection is still challen­ complexity of the pathology. If metronidazole

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
ging. Testing should be performed routinely in and vancomycin were the backbone of treatment
healthcare associated diarrhea or any unexplained in previous years, we now have new molecules:
diarrhea in the community. European and North fidaxomicin and tigecycline, and new approaches
American scientific societies recommend a strategy such as fecal microbiota transplantation to treat and
based on a two step algorithm that includes a prevent C difficile infection.
sensitive screening method followed by a more
The authors would like to thank Kathy Darling for editing the
specific method to detect free toxins. Treatment of manuscript.
C difficile infection currently relies on two molecules: Contributorship: FB drafted the section on epidemiology and
vancomycin and fidaxomicin in mild and severe diagnosis, TG drafted the section on fecal microbiota transplantation,
forms of the infection. Metronidazole is no longer BG drafted the section on treatment, all authors appraised and
amended the manuscript overall.
recommended, being inferior to vancomycin and
Declaration of interests: We have read and understood the BMJ
fidaxomicin. Fecal microbiota transplantation is policy on declaration of interests and declare the following interests:
the treatment of choice in recurrent disease. We still
Further details of The BMJ policy on financial interests is here: https://
need clinical trials to have a better idea of the target www.bmj.com/about-bmj/resources-authors/forms-policies-and-
population for bezlotoxumab. C difficile infection checklists/declaration-competing-interests
used to be a simple pathology with a simple answer. Provenance and peer review: commissioned; externally peer
Now, a better understanding of the pathophysiology reviewed.
has led to improvement of diagnostic techniques Patient involvement: No patients were directly involved in the writing
of this article.

1 Burnham C-AD, Carroll KC. Diagnosis of Clostridium difficile infection:

Research questions an ongoing conundrum for clinicians and for clinical laboratories. Clin
Microbiol Rev 2013;26:604-30. doi:10.1128/CMR.00016-13
1.Determine the prevalence of nosocomial C difficile 2 Leffler DA, Lamont JT. Clostridium difficile infection. N Engl J
infections in European hospitals Med 2015;373:287-8. doi:10.1056/NEJMc1506004
3 Magill SS, Edwards JR, Fridkin SK, Emerging Infections Program
2.Test the feasibility of adopting a standardized Healthcare-Associated Infections and Antimicrobial Use Prevalence
polymerase chain reaction ribotyping method Survey Team. Survey of health care-associated infections. N Engl J
3.Compare the types of C difficile prevalent in European Med 2014;370:2542-3. doi:10.1056/NEJMoa1306801
4 Lessa FC, Mu Y, Bamberg WM, et al. Burden of Clostridium difficile
hospitals infection in the United States. N Engl J Med 2015;372:825-34.
4.Survey the antimicrobial susceptibility of European doi:10.1056/NEJMoa1408913
5 Loo VG, Poirier L, Miller MA, et al. A predominantly clonal multi-
strains of C difficile institutional outbreak of Clostridium difficile-associated diarrhea
5.Draw up European guidelines on the prevention, with high morbidity and mortality. N Engl J Med 2005;353:2442-9.
diagnosis, treatment, and surveillance of C difficile doi:10.1056/NEJMoa051639
6 McDonald LC, Killgore GE, Thompson A, et al. An epidemic,
infections toxin gene-variant strain of Clostridium difficile. N Engl J
6.Determine the burden of C difficile infection in Med 2005;353:2433-41. doi:10.1056/NEJMoa051590
hospitals and in the community 7 Kelly CP. Can we identify patients at high risk of recurrent Clostridium
difficile infection?Clin Microbiol Infect 2012;18(Suppl 6):21-7.
7.Establish the role of C difficile in animals and its doi:10.1111/1469-0691.12046
associations with humans 8 Crobach MJT, Vernon JJ, Loo VG, et al. Understanding Clostridium
8.Determine the development and spread of plasmid difficile colonization. Clin Microbiol Rev 2018;31:1094.
doi:10.1128/CMR.00021-17
mediated metronidazole resistance in toxigenic and 9 Blixt T, Gradel KO, Homann C, et al. Asymptomatic carriers contribute
non-toxigenic C difficile isolates to nosocomial Clostridium difficile infection: a cohort study of
4508 patients. Gastroenterology 2017;152:1031-1041.e2.
9.Determine the significance of asymptomatic carrier doi:10.1053/j.gastro.2016.12.035
status for the individual patient and their environment 10 Curry SR, Muto CA, Schlackman JL, et al. Use of multilocus variable
(community, food, contact with animals) on short term number of tandem repeats analysis genotyping to determine the role
of asymptomatic carriers in Clostridium difficile transmission. Clin
and long term follow-up Infect Dis 2013;57:1094-102. doi:10.1093/cid/cit475
10.Evaluate the potential role of screening for 11 Shen A. Clostridium difficile toxins: mediators of inflammation. J
colonization in selected settings and patients Innate Immun 2012;4:149-58. doi:10.1159/000332946
12 Winston JA, Theriot CM. Impact of microbial derived secondary bile
11.Evaluate the potential methods to manipulate acids on colonization resistance against Clostridium difficile in the
human and animal gut microbiota to prevent gastrointestinal tract. Anaerobe 2016;41:44-50. doi:10.1016/j.
anaerobe.2016.05.003
C difficile colonization and infection
13 Wilson KH. Efficiency of various bile salt preparations for
12.Evaluate the effect of C difficile infection in long term stimulation of Clostridium difficile spore germination. J Clin
follow-up Microbiol 1983;18:1017-9.
14 Sorg JA, Sonenshein AL. Inhibiting the initiation of Clostridium difficile
13.Determine which group to treat with monoclonal spore germination using analogs of chenodeoxycholic acid, a bile
antibodies for prevention of C difficile infection acid. J Bacteriol 2010;192:4983-90. doi:10.1128/JB.00610-10
14.Determine the best treatment for complicated forms 15 Britton RA, Young VB. Role of the intestinal microbiota in resistance to
colonization by Clostridium difficile. Gastroenterology 2014;146:1547-
of C difficile infection 53. doi:10.1053/j.gastro.2014.01.059
15.Identify the factors that determine stool efficacy in 16 Thanissery R, Winston JA, Theriot CM. Inhibition of spore germination,
fecal microbiota transplantation to design targeted growth, and toxin activity of clinically relevant C. difficile strains by
gut microbiota derived secondary bile acids. Anaerobe 2017;45:86-
approaches 100. doi:10.1016/j.anaerobe.2017.03.004
16.Evaluate the potential role of fecal microbiota 17 Theriot CM, Koenigsknecht MJ, Carlson PEJr, et al. Antibiotic-
induced shifts in the mouse gut microbiome and metabolome
transplantation in treating first recurrence of increase susceptibility to Clostridium difficile infection. Nat
C difficile Commun 2014;5:3114. doi:10.1038/ncomms4114

14 doi: 10.1136/bmj.l4609 | BMJ 2019;366:l4609 | the bmj

 State of the Art REVIEW

18 Bauer MP, Notermans DW, van Benthem BHB, et al, ECDIS Study in human faeces. J Clin Pathol 2003;56:126-8. doi:10.1136/
Group. Clostridium difficile infection in Europe: a hospital- jcp.56.2.126

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
based survey. Lancet 2011;377:63-73. doi:10.1016/S0140- 38 Barbut F, Beaugerie L, Delas N, Fossati-Marchal S, Aygalenq P, Petit JC,
6736(10)61266-4 Infectious Colitis Study Group. Comparative value of colonic biopsy
19 Zarb P, Coignard B, Griskeviciene J, et al, National Contact Points and intraluminal fluid culture for diagnosis of bacterial acute colitis
for the ECDC pilot point prevalence survey, Hospital Contact Points in immunocompetent patients. Clin Infect Dis 1999;29:356-60.
for the ECDC pilot point prevalence survey. The European Center for doi:10.1086/520215
Disease Prevention and Control (ECDC) pilot point prevalence survey 39 Schutze GE, Willoughby RE, Committee on Infectious Diseases,
of healthcare-associated infections and antimicrobial use. Euro American Academy of Pediatrics. Clostridium difficile infection in
Surveill 2012;17:20316. doi:10.2807/ese.17.46.20316-en infants and children. Pediatrics 2013;131:196-200. doi:10.1542/
20 Davies KA, Longshaw CM, Davis GL, et al. Underdiagnosis of peds.2012-2992
Clostridium difficile across Europe: the European, multicenter, 40 Donta ST, Myers MG. Clostridium difficile toxin in asymptomatic
prospective, biannual, point-prevalence study of Clostridium difficile neonates. J Pediatr 1982;100:431-4. doi:10.1016/S0022-
infection in hospitalised patients with diarrhea (EUCLID). Lancet Infect 3476(82)80454-X
Dis 2014;14:1208-19. doi:10.1016/S1473-3099(14)70991-0 41 Aichinger E, Schleck CD, Harmsen WS, Nyre LM, Patel R. Nonutility of
21 Nyč O, Pituch H, Matějková J, Obuch-Woszczatynski P, Kuijper repeat laboratory testing for detection of Clostridium difficile by use
EJ. Clostridium difficile PCR ribotype 176 in the Czech Republic of PCR or enzyme immunoassay. J Clin Microbiol 2008;46:3795-7.
and Poland. Lancet 2011;377:1407. doi:10.1016/S0140- doi:10.1128/JCM.00684-08
6736(11)60575-8 42 Green DA, Stotler B, Jackman D, Whittier S, Della-Latta P. Clinical
22 Lim SK, Stuart RL, Mackin KE, et al. Emergence of a ribotype 244 characteristics of patients who test positive for Clostridium difficile
strain of Clostridium difficile associated with severe disease by repeat PCR. J Clin Microbiol 2014;52:3853-5. doi:10.1128/
and related to the epidemic ribotype 027 strain. Clin Infect JCM.01659-14
Dis 2014;58:1723-30. doi:10.1093/cid/ciu203 43 Khanna S, Pardi DS, Rosenblatt JE, Patel R, Kammer PP, Baddour LM.
23 Collins DA, Hawkey PM, Riley TV. Epidemiology of Clostridium An evaluation of repeat stool testing for Clostridium difficile infection
difficile infection in Asia. Antimicrob Resist Infect Control 2013;2:21. by polymerase chain reaction. J Clin Gastroenterol 2012;46:846-9.
doi:10.1186/2047-2994-2-21 doi:10.1097/MCG.0b013e3182432273
24 Rodriguez Diaz C, Seyboldt C, Rupnik M. Non-human C. difficile 44 Jun Huang G, Sivadas R, Spitzer SG, Spitzer ED, Aldrete SdelM, Kraft
reservoirs and sources: animals, food, environment. Adv Exp Med CS. Repeat Clostridium difficile PCR testing after a negative result. Am
Biol 2018;1050:227-43. doi:10.1007/978-3-319-72799-8_13 J Clin Pathol 2016;145:287-8. doi:10.1093/ajcp/aqw009
25 Knetsch CW, Connor TR, Mutreja A, et al. Whole genome 45 Debast SB, van Kregten E, Oskam KMG, van den Berg T, Van den
sequencing reveals potential spread of Clostridium difficile Berg RJ, Kuijper EJ. Effect on diagnostic yield of repeated stool
between humans and farm animals in the Netherlands, 2002 to testing during outbreaks of Clostridium difficile-associated disease.
2011. Euro Surveill 2014;19:20954. doi:10.2807/1560-7917. Clin Microbiol Infect 2008;14:622-4. doi:10.1111/j.1469-
ES2014.19.45.20954 0691.2008.01999.x
26 Suetens C, Latour K, Kärki T, et al, The Healthcare-Associated 46 Sunkesula VCK, Kundrapu S, Muganda C, Sethi AK, Donskey CJ. Does
Infections Prevalence Study Group. Prevalence of healthcare- empirical Clostridium difficile infection (CDI) therapy result in false-
associated infections, estimated incidence and composite negative CDI diagnostic test results?Clin Infect Dis 2013;57:494-
antimicrobial resistance index in acute care hospitals and long- 500. doi:10.1093/cid/cit286
term care facilities: results from two European point prevalence 47 Sethi AK, Al-Nassir WN, Nerandzic MM, Bobulsky GS, Donskey
surveys, 2016 to 2017. Euro Surveill 2018;23:e1002150. CJ. Persistence of skin contamination and environmental
doi:10.2807/1560-7917.ES.2018.23.46.1800516 shedding of Clostridium difficile during and after treatment of C.
27 Hensgens MPM, Goorhuis A, Dekkers OM, van Benthem BH, Kuijper difficile infection. Infect Control Hosp Epidemiol 2010;31:21-7.
EJ. All-cause and disease-specific mortality in hospitalized patients doi:10.1086/649016
with Clostridium difficile infection: a multicenter cohort study. Clin 48 Dubberke ER, Han Z, Bobo L, et al. Impact of clinical symptoms on
Infect Dis 2013;56:1108-16. doi:10.1093/cid/cis1209 interpretation of diagnostic assays for Clostridium difficile infections.
28 Barbut F, Bouée S, Longepierre L, Goldberg M, Bensoussan C, J Clin Microbiol 2011;49:2887-93. doi:10.1128/JCM.00891-11
Levy-Bachelot L. Excess mortality between 2007 and 2014 among 49 Jury LA, Tomas M, Kundrapu S, Sitzlar B, Donskey CJ. A Clostridium
patients with Clostridium difficile infection: a French health insurance difficile infection (CDI) stewardship initiative improves adherence
database analysis. J Hosp Infect 2018;98:21-8. doi:10.1016/j. to practice guidelines for management of CDI. Infect Control Hosp
jhin.2017.07.006 Epidemiol 2013;34:1222-4. doi:10.1086/673459
29 Khanna S, Pardi DS, Aronson SL, et al. The epidemiology of 50 Chang TW, Gorbach SL, Bartlett JB. Neutralization of Clostridium
community-acquired Clostridium difficile infection: a population- difficile toxin by Clostridium sordellii antitoxins. Infect
based study. Am J Gastroenterol 2012;107:89-95. doi:10.1038/ Immun 1978;22:418-22.
ajg.2011.398 51 George WL, Sutter VL, Citron D, Finegold SM. Selective and
30 Lessa FC, Winston LG, McDonald LC, Emerging Infections Program C. differential medium for isolation of Clostridium difficile. J Clin
difficile Surveillance Team. Burden of Clostridium difficile infection in Microbiol 1979;9:214-9.
the United States. N Engl J Med 2015;372:2369-70. doi:10.1056/ 52 Carroll KC. Tests for the diagnosis of Clostridium difficile infection:
NEJMoa1408913 the next generation. Anaerobe 2011;17:170-4. doi:10.1016/j.
31 Kotila SM, Mentula S, Ollgren J, Virolainen-Julkunen A, Lyytikäinen anaerobe.2011.01.002
O. Community- and healthcare-associated Clostridium difficile 53 Gateau C, Couturier J, Coia J, Barbut F. How to: diagnose infection
infections, Finland, 2008-2013. Emerg Infect Dis 2016;22:1747-53. caused by Clostridium difficile. Clin Microbiol Infect 2018;24:463-8.
doi:10.3201/eid2210.151492 doi:10.1016/j.cmi.2017.12.005
32 Hensgens MPM, Dekkers OM, Demeulemeester A, et al. Diarrhea in 54 Bliss DZ, Johnson S, Clabots CR, Savik K, Gerding DN. Comparison of
general practice: when should a Clostridium difficile infection be cycloserine-cefoxitin-fructose agar (CCFA) and taurocholate-CCFA for
considered? Results of a nested case-control study. Clin Microbiol recovery of Clostridium difficile during surveillance of hospitalized
Infect 2014;20:O1067-74. doi:10.1111/1469-0691.12758 patients. Diagn Microbiol Infect Dis 1997;29:1-4. doi:10.1016/
33 Barbut F, Day N, Bouée S, et al. Toxigenic Clostridium difficile carriage S0732-8893(97)00113-2
in general practice: results of a laboratory-based cohort study. Clin 55 Eckert C, Burghoffer B, Lalande V, Barbut F. Evaluation
Microbiol Infect 2019;25:588-94. doi:10.1016/j.cmi.2018.12.024 of the chromogenic agar chromID C. difficile. J Clin
34 Davies KA, Longshaw CM, Davis GL, et al. Underdiagnosis of Microbiol 2013;51:1002-4. doi:10.1128/JCM.02601-12
Clostridium difficile across Europe: the European, multicenter, 56 Reigadas E, Alcalá L, Marín M, Martín A, Bouza E. C. difficile
prospective, biannual, point-prevalence study of Clostridium difficile PCR-ribotype 023 might go undetected when using ChromId
infection in hospitalised patients with diarrhea (EUCLID). Lancet Infect C. difficile agar. Anaerobe 2017;44:34-5. doi:10.1016/j.
Dis 2014;14:1208-19. doi:10.1016/S1473-3099(14)70991-0 anaerobe.2017.01.008
35 Longtin Y, Paquet-Bolduc B, Gilca R, et al. Effect of detecting and 57 Crobach MJT, Planche T, Eckert C, et al. European Society of Clinical
isolating Clostridium difficile carriers at hospital admission on the Microbiology and Infectious Diseases: update of the diagnostic
incidence of C difficile infections: a quasi-experimental controlled guidance document for Clostridium difficile infection. Clin Microbiol
study. JAMA Intern Med 2016;176:796-804. doi:10.1001/ Infect 2016;22(Suppl 4):S63-81. doi:10.1016/j.cmi.2016.03.010
jamainternmed.2016.0177 58 Barbut F, Lalande V, Eckert C. New molecular methods for
36 Barbut F, Surgers L, Eckert C, et al. Does a rapid diagnosis the diagnosis of Clostridium difficile infections. Drugs Today
of Clostridium difficile infection impact on quality of patient (Barc) 2012;48:673-84. doi:10.1358/dot.2012.48.10.1864522
management?Clin Microbiol Infect 2014;20:136-44. 59 Buss SN, Leber A, Chapin K, et al. Multicenter evaluation of the
doi:10.1111/1469-0691.12221 BioFire FilmArray gastrointestinal panel for etiologic diagnosis
37 Freeman J, Wilcox MH. The effects of storage conditions on viability of infectious gastroenteritis. J Clin Microbiol 2015;53:915-25.
of Clostridium difficile vegetative cells and spores and toxin activity doi:10.1128/JCM.02674-14

the bmj | BMJ 2019;366:l4609 | doi: 10.1136/bmj.l4609 15

State of the Art REVIEW

60 Pollock NR, Banz A, Chen X, et al. Comparison of Clostridioides 81 Langhorst J, Boone J. Fecal lactoferrin as a noninvasive biomarker in
difficile stool toxin concentrations in adults with symptomatic inflammatory bowel diseases. Drugs Today (Barc) 2012;48:149-61.

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
infection and asymptomatic carriage using an ultrasensitive doi:10.1358/dot.2012.48.2.1732555
quantitative immunoassay. Clin Infect Dis 2019;68:78-86. 82 Barbut F, Gouot C, Lapidus N, et al. Faecal lactoferrin and calprotectin
doi:10.1093/cid/ciy415 in patients with Clostridium difficile infection: a case-control study.
61 Longtin Y, Trottier S, Brochu G, et al. Impact of the type of diagnostic Eur J Clin Microbiol Infect Dis 2017;36:2423-30. doi:10.1007/
assay on Clostridium difficile infection and complication rates in s10096-017-3080-y
a mandatory reporting program. Clin Infect Dis 2013;56:67-73. 83 Kim J, Kim H, Oh HJ, et al. Fecal calprotectin level reflects the severity
doi:10.1093/cid/cis840 of Clostridium difficile infection. Ann Lab Med 2017;37:53-7.
62 Planche TD, Davies KA, Coen PG, et al. Differences in outcome doi:10.3343/alm.2017.37.1.53
according to Clostridium difficile testing method: a prospective 84 Darkoh C, Turnwald BP, Koo HL, et al. Colonic immunopathogenesis of
multicenter diagnostic validation study of C difficile infection. Clostridium difficile infections. Clin Vaccine Immunol 2014;21:509-
Lancet Infect Dis 2013;13:936-45. doi:10.1016/S1473- 17. doi:10.1128/CVI.00770-13
3099(13)70200-7 85 Swale A, Miyajima F, Roberts P, et al. Calprotectin and lactoferrin
63 Polage CR, Gyorke CE, Kennedy MA, et al. Overdiagnosis faecal levels in patients with Clostridium difficile infection (CDI): a
of Clostridium difficile infection in the molecular test era. prospective cohort study. PLoS One 2014;9:e106118. doi:10.1371/
JAMA Intern Med 2015;175:1792-801. doi:10.1001/ journal.pone.0106118
jamainternmed.2015.4114 86 Whitehead SJ, Shipman KE, Cooper M, Ford C, Gama R. Is there any
64 Guerrero DM, Chou C, Jury LA, Nerandzic MM, Cadnum JC, Donskey value in measuring faecal calprotectin in Clostridium difficile positive
CJ. Clinical and infection control implications of Clostridium difficile faecal samples?J Med Microbiol 2014;63:590-3. doi:10.1099/
infection with negative enzyme immunoassay for toxin. Clin Infect jmm.0.067389-0
Dis 2011;53:287-90. doi:10.1093/cid/cir361 87 Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines
65 Johal SS, Hammond J, Solomon K, James PD, Mahida YR. Clostridium for Clostridium difficile infection in adults: 2010 update by the
difficile associated diarrhea in hospitalised patients: onset in Society for Healthcare Epidemiology of America (SHEA) and the
the community and hospital and role of flexible sigmoidoscopy. Infectious Diseases Society of America (IDSA).2010;31:431-55.
Gut 2004;53:673-7. doi:10.1136/gut.2003.028803 doi:10.1086/651706
66 Tang DM, Urrunaga NH, De Groot H, von Rosenvinge EC, Xie 88 LaSala PR, Ekhmimi T, Hill AK, Farooqi I, Perrotta PL. Quantitative
G, Ghazi LJ. Pseudomembranous colitis: not always caused by fecal lactoferrin in toxin-positive and toxin-negative Clostridium
Clostridium difficile. Case Rep Med 2014;2014:812704-4. difficile specimens. J Clin Microbiol 2013;51:311-3. doi:10.1128/
doi:10.1155/2014/812704 JCM.02735-12
67 Humphries RM, Uslan DZ, Rubin Z. Performance of Clostridium difficile 89 Finney J. Gastroenterostomy for cicatrizing ulcer of the pylorus. Bull
toxin enzyme immunoassay and nucleic acid amplification tests Johns Hopkins Hosp 1893;4:53-5.
stratified by patient disease severity. J Clin Microbiol 2013;51:869- 90 Bartlett JG, Chang TW, Moon N, Onderdonk AB. Antibiotic-induced
73. doi:10.1128/JCM.02970-12 lethal enterocolitis in hamsters: studies with eleven agents and
68 Crobach MJT, Dekkers OM, Wilcox MH, Kuijper EJ. European Society of evidence to support the pathogenic role of toxin-producing Clostridia.
Clinical Microbiology and Infectious Diseases (ESCMID): data review Am J Vet Res 1978;39:1525-30.
and recommendations for diagnosing Clostridium difficile-infection 91 Bartlett JG, Chang T, Taylor NS, Onderdonk AB. Colitis induced by
(CDI). Clin Microbiol Infect 2009;15:1053-66. doi:10.1111/j.1469- Clostridium difficile. Rev Infect Dis 1979;1:370-8. doi:10.1093/
0691.2009.03098.x clinids/1.2.370
69 McDonald LC, Gerding DN, Johnson S, et al. Clinical practice 92 George WL, Rolfe RD, Mulligan ME, Finegold SM. Infectious diseases
guidelines for Clostridium difficile infection in adults and children: 1979--antimicrobial agent-induced colitis: an update. J Infect
2017 update by the Infectious Diseases Society of America (IDSA) Dis 1979;140:266-8. doi:10.1093/infdis/140.2.266
and Society for Healthcare Epidemiology of America (SHEA). Clin 93 Bolton RP, Culshaw MA. Faecal metronidazole concentrations
Infect Dis 2018;66:e1-48. doi:10.1093/cid/cix1085 during oral and intravenous therapy for antibiotic associated colitis
70 Berry N, Sewell B, Jafri S, et al. Real-time polymerase chain reaction due to Clostridium difficile. Gut 1986;27:1169-72. doi:10.1136/
correlates well with clinical diagnosis of Clostridium difficile infection. gut.27.10.1169
J Hosp Infect 2014;87:109-14. doi:10.1016/j.jhin.2014.03.005 94 Teasley DG, Gerding DN, Olson MM, et al. Prospective randomized
71 Peterson LR, Manson RU, Paule SM, et al. Detection of toxigenic trial of metronidazole versus vancomycin for Clostridium-
Clostridium difficile in stool samples by real-time polymerase chain difficile-associated diarrhea and colitis. Lancet 1983;2:1043-6.
reaction for the diagnosis of C. difficile-associated diarrhea. Clin doi:10.1016/S0140-6736(83)91036-X
Infect Dis 2007;45:1152-60. doi:10.1086/522185 95 Wenisch C, Parschalk B, Hasenhündl M, Hirschl AM, Graninger W.
72 Dionne L-L, Raymond F, Corbeil J, Longtin J, Gervais P, Longtin Y. Comparison of vancomycin, teicoplanin, metronidazole, and fusidic
Correlation between Clostridium difficile bacterial load, commercial acid for the treatment of Clostridium difficile-associated diarrhea. Clin
real-time PCR cycle thresholds, and results of diagnostic tests based Infect Dis 1996;22:813-8. doi:10.1093/clinids/22.5.813
on enzyme immunoassay and cell culture cytotoxicity assay. J Clin 96 Fekety R. Guidelines for the diagnosis and management of
Microbiol 2013;51:3624-30. doi:10.1128/JCM.01444-13 Clostridium difficile-associated diarrhea and colitis. American
73 Jazmati N, Hellmich M, Ličanin B, Plum G, Kaasch AJ. PCR cycle College of Gastroenterology, Practice Parameters Committee. Am J
threshold value predicts the course of Clostridium difficile infection. Gastroenterol 1997;92:739-50.
Clin Microbiol Infect 2016;22:e7-8. doi:10.1016/j.cmi.2015.09.012 97 Zar FA, Bakkanagari SR, Moorthi KMLST, Davis MB. A comparison
74 Reigadas E, Alcalá L, Valerio M, Marín M, Martin A, Bouza E. Toxin B of vancomycin and metronidazole for the treatment of Clostridium
PCR cycle threshold as a predictor of poor outcome of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect
difficile infection: a derivation and validation cohort study. J Dis 2007;45:302-7. doi:10.1086/519265
Antimicrob Chemother 2016;71:1380-5. doi:10.1093/jac/dkv497 98 Johnson S, Louie TJ, Gerding DN, et al, Polymer Alternative for
75 Senchyna F, Gaur RL, Gombar S, Truong CY, Schroeder LF, Banaei N. CDI Treatment (PACT) investigators. Vancomycin, metronidazole,
Clostridium difficile PCR cycle threshold predicts free toxin. J Clin or tolevamer for Clostridium difficile infection: results from
Microbiol 2017;55:2651-60. doi:10.1128/JCM.00563-17 two multinational, randomized, controlled trials. Clin Infect
76 Crobach MJT, Duszenko N, Terveer EM, Verduin CM, Kuijper EJ. Nucleic Dis 2014;59:345-54. doi:10.1093/cid/ciu313
acid amplification test quantitation as predictor of toxin presence 99 Stevens VW, Nelson RE, Schwab-Daugherty EM, et al. Comparative
in Clostridium difficile infection. J Clin Microbiol 2018;56:95. effectiveness of vancomycin and metronidazole for the prevention
doi:10.1128/JCM.01316-17 of recurrence and death in patients with Clostridium difficile
77 Davies KA, Planche T, Wilcox MH. The predictive value of quantitative infection. JAMA Intern Med 2017;177:546-53. doi:10.1001/
nucleic acid amplification detection of Clostridium difficile toxin jamainternmed.2016.9045
gene for faecal sample toxin status and patient outcome. PLoS 100 McFarland LV, Elmer GW, Surawicz CM. Breaking the cycle: treatment
One 2018;13:e0205941. doi:10.1371/journal.pone.0205941 strategies for 163 cases of recurrent Clostridium difficile disease.
78 Song L, Zhao M, Duffy DC, et al. Development and validation of digital Am J Gastroenterol 2002;97:1769-75. doi:10.1111/j.1572-
enzyme-linked immunosorbent assays for ultrasensitive detection 0241.2002.05839.x
and quantification of Clostridium difficile toxins in stool. J Clin 101 Majors D, Ellis P. Risk factors for recurrent Clostridium difficile
Microbiol 2015;53:3204-12. doi:10.1128/JCM.01334-15 infections and strategies to decrease readmissions in a community
79 Sandlund J, Bartolome A, Almazan A, et al. Ultrasensitive detection hospital. Hosp Pharm 2015;50:1003-10. doi:10.1310/hpj5011-
of Clostridioides difficile toxins A and B by use of automated 1003
single-molecule counting technology. J Clin Microbiol 2018;56:825. 102 Sirbu BD, Soriano MM, Manzo C, Lum J, Gerding DN, Johnson S.
doi:10.1128/JCM.00908-18 Vancomycin taper and pulse regimen with careful follow-up for
80 Banz A, Lantz A, Riou B, et al. Sensitivity of single-molecule patients with recurrent Clostridium difficile infection. Clin Infect
array assays for detection of Clostridium difficile toxins in Dis 2017;65:1396-9. doi:10.1093/cid/cix529
comparison to conventional laboratory testing algorithms. J Clin 103 Hota SS, Sales V, Tomlinson G, et al. Oral vancomycin followed by
Microbiol 2018;56:S265. doi:10.1128/JCM.00452-18 fecal transplantation versus tapering oral vancomycin treatment for

16 doi: 10.1136/bmj.l4609 | BMJ 2019;366:l4609 | the bmj

 State of the Art REVIEW

recurrent Clostridium difficile infection: an open-label, randomized 123 Akamine CM, Ing MB, Jackson CS, Loo LK. The efficacy of intracolonic
controlled trial. Clin Infect Dis 2017;64:265-71. doi:10.1093/cid/ vancomycin for severe Clostridium difficile colitis: a case series. BMC

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
ciw731 Infect Dis 2016;16:316. doi:10.1186/s12879-016-1657-1
104 Gerber M, Ackermann G. OPT-80, a macrocyclic antimicrobial 124 Eiseman B, Silen W, Bascom GS, Kauvar AJ. Fecal enema as an
agent for the treatment of Clostridium difficile infections: adjunct in the treatment of pseudomembranous enterocolitis.
a review. Expert Opin Investig Drugs 2008;17:547-53. Surgery 1958;44:854-9.
doi:10.1517/13543784.17.4.547 125 van Nood E, Vrieze A, Nieuwdorp M, et al. Duodenal infusion of donor
105 Johnson AP. Drug evaluation: OPT-80, a narrow-spectrum macrocyclic feces for recurrent Clostridium difficile. N Engl J Med 2013;368:407-
antibiotic. Curr Opin Investig Drugs 2007;8:168-73. 15. doi:10.1056/NEJMoa1205037
106 Gualtieri M, Villain-Guillot P, Latouche J, Leonetti JP, Bastide 126 Cammarota G, Masucci L, Ianiro G, et al. Randomized clinical trial:
L. Mutation in the Bacillus subtilis RNA polymerase beta’ faecal microbiota transplantation by colonoscopy vs. vancomycin
subunit confers resistance to lipiarmycin. Antimicrob Agents for the treatment of recurrent Clostridium difficile infection. Aliment
Chemother 2006;50:401-2. doi:10.1128/AAC.50.1. Pharmacol Ther 2015;41:835-43. doi:10.1111/apt.13144
401-402.2006 127 Kelly CR, Khoruts A, Staley C, et al. Effect of fecal microbiota
107 Cornely OA, Crook DW, Esposito R, et al, OPT-80-004 Clinical transplantation on recurrence in multiply recurrent Clostridium
Study Group. Fidaxomicin versus vancomycin for infection with difficile infection: a randomized trial. Ann Intern Med 2016;165:609-
Clostridium difficile in Europe, Canada, and the USA: a double- 16. doi:10.7326/M16-0271
blind, non-inferiority, randomized controlled trial. Lancet Infect 128 Youngster I, Sauk J, Pindar C, et al. Fecal microbiota transplant for
Dis 2012;12:281-9. doi:10.1016/S1473-3099(11)70374-7 relapsing Clostridium difficile infection using a frozen inoculum from
108 Louie TJ, Miller MA, Mullane KM, et al, OPT-80-003 Clinical unrelated donors: a randomized, open-label, controlled pilot study.
Study Group. Fidaxomicin versus vancomycin for Clostridium Clin Infect Dis 2014;58:1515-22. doi:10.1093/cid/ciu135
difficile infection. N Engl J Med 2011;364:422-31. doi:10.1056/ 129 Kao D, Roach B, Silva M, et al. Effect of oral capsule–vs colonoscopy-
NEJMoa0910812 delivered fecal microbiota transplantation on recurrent Clostridium
109 Louie TJ, Cannon K, Byrne B, et al. Fidaxomicin preserves the difficile infection. JAMA 2017;318:1985-93. doi:10.1001/
intestinal microbiome during and after treatment of Clostridium jama.2017.17077
difficile infection (CDI) and reduces both toxin reexpression and 130 Lee CH, Steiner T, Petrof EO, et al. Frozen vs fresh fecal microbiota
recurrence of CDI. Clin Infect Dis 2012;55(Suppl 2):S132-42. transplantation and clinical resolution of diarrhea in patients with
doi:10.1093/cid/cis338 recurrent Clostridium difficile infection. JAMA 2016;315:142-9.
110 Aldape MJ, Packham AE, Heeney DD, Rice SN, Bryant AE, Stevens DL. doi:10.1001/jama.2015.18098
Fidaxomicin reduces early toxin A and B production and sporulation 131 Jiang ZD, Ajami NJ, Petrosino JF, et al. Randomized clinical trial:
in Clostridium difficilein vitro. J Med Microbiol 2017;66:1393-9. faecal microbiota transplantation for recurrent Clostridum difficile
doi:10.1099/jmm.0.000580 infection - fresh, or frozen, or lyophilised microbiota from a small
111 Biswas JS, Patel A, Otter JA, et al. Reduction in Clostridium difficile pool of healthy donors delivered by colonoscopy. Aliment Pharmacol
environmental contamination by hospitalized patients treated Ther 2017;45:899-908. doi:10.1111/apt.13969
with fidaxomicin. J Hosp Infect 2015;90:267-70. doi:10.1016/j. 132 Hvas CL, Dahl Jørgensen SM, Jørgensen SP, et al. Fecal microbiota
jhin.2015.01.015 transplantation is superior to fidaxomicin for treatment of recurrent
112 Chilton CH, Crowther GS, Todhunter SL, et al. Efficacy of alternative Clostridium difficile infection. Gastroenterology 2019;156:1324-
fidaxomicin dosing regimens for treatment of simulated Clostridium 1332.e3. doi:10.1053/j.gastro.2018.12.019
difficile infection in an in vitro human gut model. J Antimicrob 133 Galpérine T, Sokol H, Guery B. Fecal microbiota transplantation: do
Chemother 2015;70:2598-607. doi:10.1093/jac/dkv156 we need harmonization?Clin Infect Dis 2017;64:1292. doi:10.1093/
113 Guery B, Menichetti F, Anttila V-J, et al, EXTEND Clinical Study Group. cid/cix092
Extended-pulsed fidaxomicin versus vancomycin for Clostridium 134 Hui W, Li T, Liu W, Zhou C, Gao F. Fecal microbiota transplantation for
difficile infection in patients 60 years and older (EXTEND): a treatment of recurrent C. difficile infection: An updated randomized
randomized, controlled, open-label, phase 3b/4 trial. Lancet Infect controlled trial meta-analysis. PLoS One 2019;14:e0210016.
Dis 2018;18:296-307. doi:10.1016/S1473-3099(17)30751-X doi:10.1371/journal.pone.0210016
114 Schwanbeck J, Riedel T, Laukien F, et al. Characterization of a clinical 135 Tariq R, Pardi DS, Bartlett MG, Khanna S. Low cure rates in controlled
Clostridioides difficile isolate with markedly reduced fidaxomicin trials of fecal microbiota transplantation for recurrent Clostridium
susceptibility and a V1143D mutation in rpoB. J Antimicrob difficile infection: a systematic review and meta-analysis. Clin Infect
Chemother 2019;74:6-10. doi:10.1093/jac/dky375 Dis 2019;68:1351-8. doi:10.1093/cid/ciy721
115 Popovic N, Korac M, Nesic Z, et al. Oral teicoplanin versus oral 136 Li YT, Cai HF, Wang ZH, Xu J, Fang JY. Systematic review with meta-
vancomycin for the treatment of severe Clostridium difficile infection: analysis: long-term outcomes of faecal microbiota transplantation for
a prospective observational study. Eur J Clin Microbiol Infect Dis Clostridium difficile infection. Aliment Pharmacol Ther 2016;43:445-
2018;37:745-54. doi:10.1007/s10096-017-3169-3 57. doi:10.1111/apt.13492
116 Di Bella S, Nisii C, Petrosillo N. Is tigecycline a suitable option 137 Youngster I, Russell GH, Pindar C, Ziv-Baran T, Sauk J, Hohmann EL.
for Clostridium difficile infection? Evidence from the literature. Oral, capsulized, frozen fecal microbiota transplantation for relapsing
Int J Antimicrob Agents 2015;46:8-12. doi:10.1016/j. Clostridium difficile infection. JAMA 2014;312:1772-8. doi:10.1001/
ijantimicag.2015.03.012 jama.2014.13875
117 Gergely Szabo B, Kadar B, Szidonia Lenart K, et al. Use of 138 Costello SP, Conlon MA, Vuaran MS, Roberts-Thomson IC, Andrews
intravenous tigecycline in patients with severe Clostridium difficile JM. Faecal microbiota transplant for recurrent Clostridium difficile
infection: a retrospective observational cohort study. Clin Microbiol infection using long-term frozen stool is effective: clinical efficacy and
Infect 2016;22:990-5. doi:10.1016/j.cmi.2016.08.017 bacterial viability data. Aliment Pharmacol Ther 2015;42:1011-8.
118 Bishop EJ, Tiruvoipati R, Metcalfe J, Marshall C, Botha J, Kelley PG. The doi:10.1111/apt.13366
outcome of patients with severe and severe-complicated Clostridium 139 Ianiro G, Masucci L, Quaranta G, et al. Randomized clinical trial: faecal
difficile infection treated with tigecycline combination therapy: a microbiota transplantation by colonoscopy plus vancomycin for the
retrospective observational study. Intern Med J 2018;48:651-60. treatment of severe refractory Clostridium difficile infection-single
doi:10.1111/imj.13742 versus multiple infusions. Aliment Pharmacol Ther 2018;48:152-9.
119 Manea E, Sojo-Dorado J, Jipa RE, Benea SN, Rodríguez-Baño J, doi:10.1111/apt.14816
Hristea A. The role of tigecycline in the management of Clostridium 140 Weingarden AR, Hamilton MJ, Sadowsky MJ, Khoruts A. Resolution
difficile infection: a retrospective cohort study. Clin Microbiol of severe Clostridium difficile infection following sequential fecal
Infect 2018;24:180-4. doi:10.1016/j.cmi.2017.06.005 microbiota transplantation. J Clin Gastroenterol 2013;47:735-7.
120 Debast SB, Bauer MP, Kuijper EJ, European Society of Clinical doi:10.1097/MCG.0b013e31829004ae
Microbiology and Infectious Diseases. European Society of Clinical 141 Fischer M, Sipe B, Cheng Y-W, et al. Fecal microbiota transplant in
Microbiology and Infectious Diseases: update of the treatment severe and severe-complicated Clostridium difficile: A promising
guidance document for Clostridium difficile infection. Clin Microbiol treatment approach. Gut Microbes 2017;8:289-302. doi:10.1080/1
Infect 2014;20(Suppl 2):1-26. doi:10.1111/1469-0691.12418 9490976.2016.1273998
121 Rokas KEE, Johnson JW, Beardsley JR, Ohl CA, Luther VP, Williamson 142 Fischer M, Sipe BW, Rogers NA, et al. Faecal microbiota
JC. The addition of intravenous metronidazole to oral vancomycin transplantation plus selected use of vancomycin for severe-
is associated with improved mortality in critically ill patients with complicated Clostridium difficile infection: description of a protocol
Clostridium difficile infection. Clin Infect Dis 2015;61:934-41. with high success rate. Aliment Pharmacol Ther 2015;42:470-6.
doi:10.1093/cid/civ409 doi:10.1111/apt.13290
122 Erikstrup LT, Aarup M, Hagemann-Madsen R, et al. Treatment of 143 Agrawal M, Aroniadis OC, Brandt LJ, et al. The long-term efficacy
Clostridium difficile infection in mice with vancomycin alone is and safety of fecal microbiota transplant for recurrent, severe,
as effective as treatment with vancomycin and metronidazole and complicated Clostridium difficile infection in 146 elderly
in combination. BMJ Open Gastroenterol 2015;2:e000038. individuals. J Clin Gastroenterol 2016;50:403-7. doi:10.1097/
doi:10.1136/bmjgast-2015-000038 MCG.0000000000000410

the bmj | BMJ 2019;366:l4609 | doi: 10.1136/bmj.l4609 17

State of the Art REVIEW

144 Camacho-Ortiz A, Gutiérrez-Delgado EM, Garcia-Mazcorro JF, et al. 165 Weingarden AR, Chen C, Zhang N, et al. Ursodeoxycholic acid inhibits
Randomized clinical trial to evaluate the effect of fecal microbiota Clostridium difficile spore germination and vegetative growth,

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
transplant for initial Clostridium difficile infection in intestinal and prevents the recurrence of ileal pouchitis Associated With the
microbiome. PLoS One 2017;12:e0189768. doi:10.1371/journal. Infection. J Clin Gastroenterol 2016;50:624-30. doi:10.1097/
pone.0189768 MCG.0000000000000427
145 Juul FE, Garborg K, Bretthauer M, et al. Fecal microbiota 166 Nayak SU, Griffiss JM, Blumer J, et al. Safety, tolerability, systemic
transplantation for primary Clostridium difficile infection. N Engl J exposure, and metabolism of CRS3123, a methionyl-tRNA synthetase
Med 2018;378:2535-6. doi:10.1056/NEJMc1803103 inhibitor developed for treatment of Clostridium difficile, in a Phase
146 Kelly CR, Ihunnah C, Fischer M, et al. Fecal microbiota transplant for 1 Study. Antimicrob Agents Chemother 2017;61:531. doi:10.1128/
treatment of Clostridium difficile infection in immunocompromised AAC.02760-16
patients. Am J Gastroenterol 2014;109:1065-71. doi:10.1038/ 167 Mullane K, Lee C, Bressler A, et al. Multicenter, randomized
ajg.2014.133 clinical trial to compare the safety and efficacy of LFF571 and
147 Trubiano JA, Gardiner B, Kwong JC, Ward P, Testro AG, Charles vancomycin for Clostridium difficile infections. Antimicrob Agents
PG. Faecal microbiota transplantation for severe Clostridium Chemother 2015;59:1435-40. doi:10.1128/AAC.04251-14
difficile infection in the intensive care unit. Eur J Gastroenterol 168 Rashid M-U, Lozano HM, Weintraub A, Nord CE. In vitro activity
Hepatol 2013;25:255-7. doi:10.1097/MEG.0b013e32835b2da9 of cadazolid against Clostridium difficile strains isolated
148 Marcos LA, Gersh A, Blanchard K, et al. Fecal transplantation to treat from primary and recurrent infections in Stockholm, Sweden.
initial severe Clostridium difficile infection with sepsis. J Miss State Anaerobe 2013;20:32-5. doi:10.1016/j.anaerobe.2013.02.003
Med Assoc 2015;56:38-40. 169 Dale N, Gerding MD, Cornely OA, et al. Cadazolid for the treatment
149 Gweon T-G, Lee KJ, Kang DH, et al. A case of toxic megacolon caused of Clostridium difficile infection: results of two doubleblind, double-
by clostridium difficile infection and treated with fecal microbiota dummy, non-inferiority, randomized controlled phase 3 trials. Lancet
transplantation. Gut Liver 2015;9:247-50. doi:10.5009/gnl14152 Infect Dis 2018;19:265-74.
150 Yu S, Abdelkarim A, Nawras A, et al. Fecal transplant for 170 Daley P, Louie T, Lutz JE, et al. Surotomycin versus vancomycin in
treatment of toxic megacolon associated with Clostridium difficile adults with Clostridium difficile infection: primary clinical outcomes
colitis in a patient with Duchenne muscular dystrophy. Am J from the second pivotal, randomized, double-blind, Phase 3 trial. J
Ther 2016;23:e609-13. doi:10.1097/MJT.0000000000000062 Antimicrob Chemother 2017;72:3462-70. doi:10.1093/
151 Gweon T-G, Kim J, Lim C-H, et al. Fecal microbiota transplantation jac/dkx299
using upper gastrointestinal tract for the treatment of refractory 171 Sangster W, Hegarty JP, Stewart DBSr. Phage tail-like particles kill
or severe complicated Clostridium difficile infection in elderly Clostridium difficile and represent an alternative to conventional
patients in poor medical condition: the first study in an Asian antibiotics. Surgery 2015;157:96-103. doi:10.1016/j.
country. Gastroenterol Res Pract 2016;2016:2687605. surg.2014.06.015
doi:10.1155/2016/2687605 172 Borriello SP, Barclay FE. Protection of hamsters against Clostridium
152 Hocquart M, Lagier J-C, Cassir N, et al. Early fecal microbiota difficile ileocaecitis by prior colonisation with non-pathogenic strains.
transplantation improves survival in severe Clostridium difficile J Med Microbiol 1985;19:339-50. doi:10.1099/00222615-19-3-
infections. Clin Infect Dis 2018;66:645-50. doi:10.1093/cid/cix762 339
153 Staley C, Kelly CR, Brandt LJ, Khoruts A, Sadowsky MJ. Complete 173 Seal D, Borriello SP, Barclay F, Welch A, Piper M, Bonnycastle M.
microbiota engraftment is not essential for recovery from Treatment of relapsing Clostridium difficile diarrhea by administration
recurrent Clostridium difficile infection following fecal microbiota of a non-toxigenic strain. Eur J Clin Microbiol 1987;6:51-3.
transplantation. MBio 2016;7:01965. doi:10.1128/mBio.01965-16 doi:10.1007/BF02097191
154 Weingarden AR, Dosa PI, DeWinter E, et al. Changes in colonic bile 174 Villano SA, Seiberling M, Tatarowicz W, Monnot-Chase E, Gerding DN.
acid composition following fecal microbiota transplantation are Evaluation of an oral suspension of VP20621, spores of nontoxigenic
sufficient to control Clostridium difficile germination and growth. Clostridium difficile strain M3, in healthy subjects. Antimicrob Agents
PLoS One 2016;11:e0147210. doi:10.1371/journal.pone.0147210 Chemother 2012;56:5224-9. doi:10.1128/AAC.00913-12
155 Brown JRM, Flemer B, Joyce SA, et al. Changes in microbiota 175 Gerding DN, Meyer T, Lee C, et al. Administration of spores
composition, bile and fatty acid metabolism, in successful faecal of nontoxigenic Clostridium difficile strain M3 for prevention
microbiota transplantation for Clostridioides difficile infection. BMC of recurrent C. difficile infection: a randomized clinical trial.
Gastroenterol 2018;18:131. doi:10.1186/s12876-018-0860-5 JAMA 2015;313:1719-27. doi:10.1001/jama.2015.3725
156 Seekatz AM, Aas J, Gessert CE, et al. Recovery of the gut microbiome 176 Beinortas T, Burr NE, Wilcox MH, Subramanian V. Comparative efficacy
following fecal microbiota transplantation. MBio 2014;5:e00893-14. of treatments for Clostridium difficile infection: a systematic review
doi:10.1128/mBio.00893-14 and network meta-analysis. Lancet Infect Dis 2018;18:1035-44.
157 Ott SJ, Waetzig GH, Rehman A, et al. Efficacy of sterile fecal filtrate doi:10.1016/S1473-3099(18)30285-8
transfer for treating patients with Clostridium difficile infection. 177 Nelson RL, Suda KJ, Evans CT. Antibiotic treatment for Clostridium
Gastroenterology 2017;152:799-811.e7. doi:10.1053/j. difficile-associated diarrhea in adults. Cochrane Database Syst
gastro.2016.11.010 Rev 2017;3:CD004610. doi:10.1002/14651858.CD004610.pub5
158 Bojanova DP, Bordenstein SR. Fecal transplants: what is being 178 Garey KW, Ghantoji SS, Shah DN, et al. A randomized, double-blind,
transferred?PLoS Biol 2016;14:e1002503-12. doi:10.1371/journal. placebo-controlled pilot study to assess the ability of rifaximin
pbio.1002503 to prevent recurrent diarrhea in patients with Clostridium difficile
159 Woodworth MH, Carpentieri C, Sitchenko KL, Kraft CS. Challenges infection. J Antimicrob Chemother 2011;66:2850-5. doi:10.1093/
in fecal donor selection and screening for fecal microbiota jac/dkr377
transplantation: A review. Gut Microbes 2017;8:225-37. doi:10.108 179 Major G, Bradshaw L, Boota N, et al. Follow-on RifAximin for the
0/19490976.2017.1286006 prevention of recurrence following standard treatment of infection
160 Sokol H, Galperine T, Kapel N, et al, French Group of Faecal with Clostridium difficile (RAPID): a randomized placebo controlled
microbiota Transplantation (FGFT). Faecal microbiota transplantation trial. Gut 2018;0:1-8. doi:10.1136/gutjnl-2018-316794
in recurrent Clostridium difficile infection: Recommendations from 180 Reigadas E, Alcalá L, Gómez J, et al. Breakthrough Clostridium
the French Group of Faecal microbiota Transplantation. Dig Liver difficile infection in cirrhotic patients receiving Rifaximin. Clin Infect
Dis 2016;48:242-7. doi:10.1016/j.dld.2015.08.017 Dis 2018;66:1086-91. doi:10.1093/cid/cix918
161 Cammarota G, Ianiro G, Tilg H, et al, European FMT Working Group. 181 Gao XW, Mubasher M, Fang CY, Reifer C, Miller LE. Dose-response
European consensus conference on faecal microbiota transplantation efficacy of a proprietary probiotic formula of Lactobacillus
in clinical practice. Gut 2017;66:569-80. doi:10.1136/ acidophilus CL1285 and Lactobacillus casei LBC80R for antibiotic-
gutjnl-2016-313017 associated diarrhea and Clostridium difficile-associated diarrhea
162 US Food & Drug Administration. 2019. https://www.fda.gov/ prophylaxis in adult patients. Am J Gastroenterol 2010;105:1636-
vaccines-blood-biologics/safety-availability-biologics/important- 41. doi:10.1038/ajg.2010.11
safety-alert-regarding-use-fecal-microbiota-transplantation-and-risk- 182 Selinger CP, Bell A, Cairns A, Lockett M, Sebastian S, Haslam N.
serious-adverse Probiotic VSL#3 prevents antibiotic-associated diarrhea in a
163 Vickers R, Robinson N, Best E, Echols R, Tillotson G, Wilcox M. A double-blind, randomized, placebo-controlled clinical trial. J Hosp
randomized phase 1 study to investigate safety, pharmacokinetics Infect 2013;84:159-65. doi:10.1016/j.jhin.2013.02.019
and impact on gut microbiota following single and multiple oral 183 Ouwehand AC, DongLian C, Weijian X, et al. Probiotics reduce
doses in healthy male subjects of SMT19969, a novel agent symptoms of antibiotic use in a hospital setting: a randomized
for Clostridium difficile infections. BMC Infect Dis 2015;15:91. dose response study. Vaccine 2014;32:458-63. doi:10.1016/j.
doi:10.1186/s12879-015-0759-5 vaccine.2013.11.053
164 Vickers RJ, Tillotson GS, Nathan R, et al, CoDIFy study group. Efficacy 184 Dubberke ER, Lee CH, Orenstein R, Khanna S, Hecht G, Gerding DN.
and safety of ridinilazole compared with vancomycin for the Results from a randomized, placebo-controlled clinical trial of a
treatment of Clostridium difficile infection: a phase 2, randomized, RBX2660—a microbiota-based drug for the prevention of recurrent
double-blind, active-controlled, non-inferiority study. Lancet Infect Clostridium difficile infection. Clin Infect Dis 2018;67:1198-204.
Dis 2017;17:735-44. doi:10.1016/S1473-3099(17)30235-9 doi:10.1093/cid/ciy259

18 doi: 10.1136/bmj.l4609 | BMJ 2019;366:l4609 | the bmj

 State of the Art REVIEW

185 Khanna S, Pardi DS, Kelly CR, et al. A novel microbiome therapeutic difficile, in healthy volunteers. Vaccine 2016;34:2585-92.
increases gut microbial diversity and prevents recurrent Clostridium doi:10.1016/j.vaccine.2016.03.098

BMJ: first published as 10.1136/bmj.l4609 on 20 August 2019. Downloaded from http://www.bmj.com/ on 9 September 2019 by guest. Protected by copyright.
difficile infection. J Infect Dis 2016;214:173-81. doi:10.1093/infdis/ 192 Sheldon E, Kitchin N, Peng Y, et al. A phase 1, placebo-controlled,
jiv766 randomized study of the safety, tolerability, and immunogenicity
186 Babcock GJ, Broering TJ, Hernandez HJ, et al. Human monoclonal of a Clostridium difficile vaccine administered with or without
antibodies directed against toxins A and B prevent Clostridium aluminum hydroxide in healthy adults. Vaccine 2016;34:2082-91.
difficile-induced mortality in hamsters. Infect Immun 2006;74:6339- doi:10.1016/j.vaccine.2016.03.010
47. doi:10.1128/IAI.00982-06 193 Kokai-Kun JF, Roberts T, Coughlin O, et al. The oral β-lactamase
187 Lowy I, Molrine DC, Leav BA, et al. Treatment with monoclonal SYN-004 (ribaxamase) degrades ceftriaxone excreted into
antibodies against Clostridium difficile toxins. N Engl J the intestine in Phase 2a clinical studies. Antimicrob Agents
Med 2010;362:197-205. doi:10.1056/NEJMoa0907635 Chemother 2017;61:02197. doi:10.1128/AAC.02197-16
188 Wilcox MH, Gerding DN, Poxton IR, et al, MODIFY I and MODIFY II 194 de Gunzburg J, Ducher A, Modess C, et al. Targeted adsorption of
Investigators. Bezlotoxumab for prevention of recurrent Clostridium molecules in the colon with the novel adsorbent-based medicinal
difficile infection. N Engl J Med 2017;376:305-17. doi:10.1056/ product, DAV132: A proof of concept study in healthy subjects. J Clin
NEJMoa1602615 Pharmacol 2015;55:10-6. doi:10.1002/jcph.359
189 Kotloff KL, Wasserman SS, Losonsky GA, et al. Safety and 195 Zhang B-Z, Cai J, Yu B, et al. A DNA vaccine targeting TcdA and TcdB
immunogenicity of increasing doses of a Clostridium difficile toxoid induces protective immunity against Clostridium difficile. BMC Infect
vaccine administered to healthy adults. Infect Immun 2001;69:988- Dis 2016;16:596. doi:10.1186/s12879-016-1924-1
95. doi:10.1128/IAI.69.2.988-995.2001 196 Baliban SM, Michael A, Shammassian B, et al. An optimized,
190 de Bruyn G, Saleh J, Workman D, et al, H-030-012 Clinical synthetic DNA vaccine encoding the toxin A and toxin B receptor
Investigator Study Team. Defining the optimal formulation and binding domains of Clostridium difficile induces protective antibody
schedule of a candidate toxoid vaccine against Clostridium responses in vivo. Infect Immun 2014;82:4080-91. doi:10.1128/
difficile infection: A randomized Phase 2 clinical trial. IAI.01950-14
Vaccine 2016;34:2170-8. doi:10.1016/j.vaccine.2016.03.028 197 Donald RGK, Flint M, Kalyan N, et al. A novel approach to generate
191 Bézay N, Ayad A, Dubischar K, et al. Safety, immunogenicity and dose a recombinant toxoid vaccine against Clostridium difficile.
response of VLA84, a new vaccine candidate against Clostridium Microbiology 2013;159:1254-66. doi:10.1099/mic.0.066712-0

No commercial reuse: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe