Controlling Clostridium difficile

Although first described in 1935, the clinical importance of C. difficile was not recognised until several patients died from fulminant colitis after receiving clindamycin in the 1970s.The incidence and severity of C. difficile has increased substantially in the last 20 years in the developed world.This trend is most prominent in elderly people in hospital and is increasingly recognised in residential aged-care facilities.In the USA, C. difficile is now the 18th leading cause of death in those over 65 years old.5 There is also an increased incidence of C. difficile infection outside of healthcare facilities.In a targeted surveillance program in Victoria, 16% of C. difficile cases were community-associated. 6 Of cases identified in Queensland, 37% had community-onset diarrhoea (unpublished data).Similarly, in surveys in the USA, up to 41% of cases were not associated with recent hospitalisation.7 In Australia, there is no published evidence of increasing incidence of C. difficile infection.However, until recently there was no uniform diagnostic approach or surveillance.8 In Victoria, between October 2010 and March 2011 there were 370 healthcare-associated cases (1.7 per 10 000 occupied bed days).6 Outbreaks of hypervirulent C. difficileIn 2005 a novel strain of C. difficile, now known as PCR ribotype 027, led to an outbreak of severe diarrhoea and markedly increased mortality in hospitalised patients in Quebec, Canada.9 Cases were significantly more likely to have received fluoroquinolones, in particular moxifloxacin and