CLOSTRIDIUM DIFFICILE COLITIS AND ANTIBIOTICS

Clostridium difficile is an uncommon disease that has been on the increase and is felt to be mainly a side effect of antibiotic use. Clindamycin is a commonly used and appropriate antibiotic for oral infections. It is, however, a second or third line drug for me as an oral surgeon because of the risk of C difficile colitis. Clindamycin is actually not as good an antibiotic as Augmentin for oral/facial infections where anaerobic bacteria are suspected. Penicillin is still our first line drug followed by Amoxicillin and certain cephalosporins such as cephalexin. For the typical mild oral infection, the next line would be Augmentin. For penicillin allergic patients, my first line is erythromycin or azithromycin. As we get into the more serious infections, I modify my regimen on a case-by-case basis. Clindamycin is a commonly used and appropriate antibiotic for oral infections. It is popular and used by many dentists and oral surgeons. Again, I would typically use it as a second line drug behind erythromycin or Azithromycin for the penicillin allergic patient.

SOME NOTES ON CLOSTRIDIUM DIFFICILE

Clostridium difficile is an opportunistic pathogen, typically colonizing the intestinal tract after alteration of the normal flora by antimicrobial therapy (antibiotics). Inoculation is along the fecal-to-oral route. The prevalence of antibiotic-associated colitis has increased alongside the expansion of antibiotic use. The organism was first identified in stool samples of healthy neonates and named Bacillus difficilis owing to the difficulty of attempts to isolate and culture it. However, C difficile was not identified as the causative agent in antibiotic-associated colitis until 1978. Its main virulence factor is the ability to elaborate exotoxins, designated toxin A and toxin B, that bind to receptors on intestinal epithelial cells, creating the clinical manifestations of C difficile-associated colitis.

Some risk factors for C difficile infection (CDI) have been identified. Most, but not all, cases have been associated with antibiotic use. Hospitalization or assisted living facility admission are strongly associated risk factors, as are an age older than 65 years and debilitating illness. Although the associations are less clear, enteral feeding, use of proton pump inhibitors, abdominal surgery, cancer chemotherapy, and stem cell transplantation have gained attention as potential risk factors. In addition to therapeutic antibiotic use, perioperative antibiotic prophylaxis has been shown to confer risk for CDI. Of significance, CDI can occur in the absence of identifiable risk factors.  

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