Recurrent Clostridium difficile infections: The importance of the intestinal microbiota

Table 1 Independent risk factors for Clostridium difficile infections (adapted from[9])

Antibiotic use (especially 3rd generation cephalosporins, fluoroquinolones)

Patients older than 60 yr

Admission in previous 60 d

Use of proton pump inhibitors and histamine-2 blockers

Use of anti-motility agent

Mechanical ventilation

Hypoalbuminemia

Table 2 Clinical presentation of Clostridium difficile infections (adapted from[44])

	Clinical manifestations	Laboratory and imaging studies
C. difficile diarrhea	Diarrhea	Colonoscopy: unremarkable
	Abdominal pain
	+/- fever
C. difficile colitis	Diarrhea	Leukocytosis
	Abdominal pain	Colonoscopy: patchy or diffuse erythematous colitis without pseudomembranes
	Fever
Pseudomembranous colitis	Diarrhea	Leukocytosis
	Abdominal pain	Colonoscopy: pathognomonic pseudomembranes (yellow plaques 2-20 mm)
	Fever
Fulminant colitis	Profuse diarrhea or ileus	Leukocytosis (sometimes white blood cell count > 4 × 109/L)
	Abdominal pain	Elevated serum lactate
	Fever	Sigmoidoscopy: pseudomembranes
	+/- signs of shock	Abdominal computed tomography scanner: megacolon, +/- bowel perforation

C. difficile:Clostridium difficile.

Table 3 Severity of Clostridium difficile (adapted from[1,10,11])

Severity criteria according to American experts	Non severe CDI	White blood cell count < 15 × 109/L and creatinine level < 1.5 × baseline
	Severe CDI	White blood cell count > 15 × 109/L or creatinine level > 1.5 × baseline
	Severe and complicated CDI	Hypotension or shock or ileus or megacolon
Severity criteria according to European experts	Severe CDI	Age > 65 yr or severe comorbidities or intensive care admission or immunodeficiency
		or
		Presence of ≥ 1 of the following criteria:
		Fever ≥ 38.5  °C
		Shivering
		Hemodynamic instability
		Signs of peritonitis
		Signs of ileus
		White blood cell count > 15 × 109/L
		Creatinine level > 1.5 × baseline
		Elevated serum lactate
		Pseudomembranous colitis (colonoscopy)
		Distension of large intestine (computed tomography, CT scan)
		Colonic wall thickening (CT scan)
		Pericolonic fat stranding (CT scan)
		Ascites not explained by other causes

CDI: Clostridium difficile infection; CT: Computed tomography.

Table 4 Characteristics of some recent studies concerning fecal microbiota transplantation in recurrent Clostridium difficile infection treatment

Ref.	Study type	Patients (n)	FMT delivery modality	Success rate	Follow-up
Garborg et al[35], 2010	Retrospective study	40	Gastroscope	73% after 1 instillation	10 wk
			Colonoscope	83% after 2 instillations
Burke et al[36], 2013	Review	115	Naso-enteric tube	89.6%	2 mo to 5 yr
			Gastroscope
			Colonoscope
			Retention enema
Gough et al[32], 2011	Review	317	Naso-enteric tube	89% after 1 instillation	3 d to 5 yr
			Gastroscope	92% after ≥ 2 instillations
			Colonoscope
			Retention enema
Kassam et al[33], 2013	Meta-analysis	273	Naso-enteric tube	89%	2 wk to 8 yr
			Gastroscope
			Colonoscope
			Retention enema
Van Nood et al[38], 2013	Randomized controlled trial	43	Naso-duodenal tube	81.3% after 1 instillation	10 wk
				93.8% after 2 instillations

FMT: Fecal microbiota transplantation.