Content area
Full text
Clostridium difficile is the commonest enteric pathogen in patients in hospital. In 1978 C difficile was first recognised as the main cause of pseudomembranous colitis and antibiotic associated colitis and diarrhoea. 1 2 3 4 Since then, extensive studies have helped to elucidate the role of this organism in human disease, but there are still some issues to be resolved. In this paper we review the work that led to the recognition of C difficile and discuss our current knowledge on the pathogenesis, diagnosis, and management of disease associated with C difficile.
Historical background
Pseudomembranous lesions of the intestine were first described in 1893 by Finney in a postoperative patient, 5 but pseudomembranous colitis was relatively rare until the 1950s, when it became a common complication of antibiotic treatment after the introduction of penicillin, tetracycline, and chloramphenicol. At that time Staphylococcus aureus was thought to be the organism causing this condition, and the condition was called staphylococcal enteritis and was later treated with oral vancomycin. 6 This view was not challenged until the 1970s, when a resurgence of interest in pseudomembranous colitis occurred after a report that, in a prospective study of 200 patients treated with the antibiotic clindamycin, 21% developed diarrhoea and 10% were shown to have pseudomembranous colitis by endoscopy. 7 Subsequent testing of stool specimens showed the presence of C difficile toxin. 7 This strong association with clindamycin led to the introduction of the term clindamycin associated colitis 8 and to a challenge to Staphylococcus aureus as the cause of pseudomembranous colitis.
CLOSTRIDIUM DIFFICILE
In 1935 Hall and O'Toole first isolated this organism, designated Bacillus difficilis, from the meconium and faeces of newborn infants. 9 The organism was shown to produce a lethal toxin in experimental animals, but since it was commonly found in the stools of healthy neonates it was classified as commensal and subsequently attracted little attention until 1974, when a comprehensive study showed that C difficile was widespread in nature and could be isolated from the stools of several animal species and from patients' faeces and genitourinary tracts. 10 11 It was also noted that most strains of C difficile produced a lethal toxin, but no further work was undertaken.
The link between clindamycin associated colitis and C difficile...