title: Clostridium difficile infection in older adults: a review and update on its management.
abstract: BACKGROUND
  Clostridium difficile is a main cause of health care-associated infections. The incidence and severity have been increasing. Elderly persons are at an increased risk of morbidity and mortality from C. difficile infection (CDI). Relatively few advances have been made in the treatment of CDI since it was first identified as a cause of antibiotic-associated diarrhea more than 30 years ago.
  
  
  OBJECTIVE
  This article reviews CDI and provides an update on its treatment, including recently published clinical practice guidelines and the recently approved drug, fidaxomicin.
  
  
  METHODS
  English-language literature was identified through a search of PubMed (1966-October 2011), Iowa Drug Information Service (1966-October 2011), and International Pharmaceutical Abstracts (1970-October 2011). Key search terms included Clostridium difficile, Clostridium infections, pseudomembranous colitis, antibiotic-associated diarrhea, Clostridium difficile-associated diarrhea, elderly, geriatric, epidemiology, microbiology, diagnosis, risk factors, treatment, drug therapy, vancomycin, metronidazole, and fidaxomicin.
  
  
  RESULTS
  Metronidazole and vancomycin remain the mainstays of CDI treatment. Current guidelines recommend oral metronidazole for initial mild to moderate episodes or first recurrence. Oral vancomycin is recommended for initial severe episodes, or first or second recurrence. Fidaxomicin was approved in 2011 for treatment of CDI, but its place in therapy has yet to be determined. Other antibiotics have been used with variable success. Saccharomyces boulardii is the only probiotic that has shown efficacy in CDI. Fecal transplants have been used successfully in some patients, but randomized studies are needed. Immune therapy with a vaccine and monoclonal antibodies is being studied in clinical trials.
  
  
  CONCLUSIONS
  Treatment of CDI is challenging due to the limited number of drugs that have proven to be effective, concerns about antibiotic resistance, and recurring disease. The recent approval of fidaxomicin provides a new alternative. Immune therapy will likely play a greater role in the future.
authors.affiliation: Iowa Drug Information Service, University of Iowa College of Pharmacy, Iowa City, Iowa, USA. vicki-kee@uiowa.edu
authors.forename: Vicki R
authors.initials: VR
authors.lastname: Kee
mesh_terms: D000368:Aged; D000617:Aminoglycosides / Q000627:therapeutic use; D000900:Anti-Bacterial Agents / Q000009:adverse effects*; D000890:Anti-Infective Agents / Q000627:therapeutic use*; D016360:Clostridioides difficile; D003015:Clostridium Infections / Q000139:chemically induced / Q000175:diagnosis / Q000188:drug therapy*; D003967:Diarrhea / Q000382:microbiology*; D004761:Enterocolitis, Pseudomembranous / Q000188:drug therapy*; D000077732:Fidaxomicin; D006801:Humans; D017053:Infection Control / Q000379:methods; D008795:Metronidazole / Q000627:therapeutic use; D012307:Risk Factors; D014640:Vancomycin / Q000627:therapeutic use
chemical_list: D000617:Aminoglycosides; D000900:Anti-Bacterial Agents; D000890:Anti-Infective Agents; D008795:Metronidazole; D014640:Vancomycin; D000077732:Fidaxomicin