Clostridium difficile Infection: Considerations in the Geriatric Population

  • Molly Flanagan
  • Paula Ferrada


Clostridium difficile infection (CDI) in the elderly is an increasingly significant problem in industrialized countries [1]. Diarrhea in elderly patients causes significant morbidity, ranging from incontinence and isolation to dehydration, hospitalization, and death [2]. The complicated interplay of host and environmental risk factors creates a setting in which elderly patients are particularly susceptible to CDI [3–7].


  1. 1.
    Centers for disease control and prevention. QuickStats: Rates of Clostridium difficile infection among hospitalized patients aged C65 years,* by age group—National Hospital Discharge Survey, United States, 1996–2009.
  2. 2.
    Trinh C, Prabhakar K. Diarrheal diseases in the elderly. Clin Geriatr Med. 2007;23(4):833–56. Scholar
  3. 3.
    Britton RA, Young VB. Role of the intestinal microbiota in resistance to colonization by Clostridium difficile. Gastroenterology. 2014;146(6):1547–53. Scholar
  4. 4.
    Eaton SR, Mazuski JE. Overview of severe Clostridium difficile infection. Crit Care Clin. 2013;29(4):827–39. Scholar
  5. 5.
    Mizusawa M, Doron S, Gorbach S. Clostridium difficile diarrhea in the elderly: current issues and management options. Drugs Aging. 2015;32(8):639–47. Scholar
  6. 6.
    Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol. 2010;31:431–55.CrossRefPubMedGoogle Scholar
  7. 7.
    Zacharioudakis IM, Zervou FN, Pliakos EE, Ziakas PD, Mylonakis E. Colonization with toxinogenic C. difficile upon hospital admission, and risk of infection: a systematic review and meta-analysis. Am J Gastroenterol. 2015;110(3):381–90; quiz 391. doi:
  8. 8.
    Sartelli M, Malangoni MA, Abu-Zidan FM, et al. WSES guidelines for management of Clostridium difficile infection in surgical patients. World J Emerg Surg. 2015;10:38.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Bauer MP, Notermans DW, van Benthem BH, et al. Clostridium difficile infection in europe: a hospital-based survey. Lancet. 2011;377(9759):63–73. Scholar
  10. 10.
    Garey KW, Sethi S, Yadav Y, DuPont HL. Meta-analysis to assess risk factors for recurrent Clostridium difficile infection. J Hosp Infect. 2008;70(4):298–304. Scholar
  11. 11.
    Rodriguez C, Korsak N, Taminiau B, et al. Clostridium difficile infection in elderly nursing home residents. Anaerobe. 2014;30:184–7. Scholar
  12. 12.
    Denève C, Janoir C, Poilane I, Fantinato C, Collignon A. New trends in Clostridium difficile virulence and pathogenesis. Int J Antimicrob Agents. 2009;33(Suppl 1):S24–8.–8579(09)70012-3.CrossRefPubMedGoogle Scholar
  13. 13.
    Awad MM, Johanesen PA, Carter GP, Rose E, Lyras D. Clostridium difficile virulence factors: insights into an anaerobic spore-forming pathogen. Gut Microbes. 2014;5(5):579–93. Scholar
  14. 14.
    Kuehne SA, Cartman ST, Heap JT, Kelly ML, Cockayne A, Minton NP. The role of toxin A and toxin B in Clostridium difficile infection. Nature. 2010;467(7316):711–3. Scholar
  15. 15.
    Kuehne SA, Collery MM, Kelly ML, Cartman ST, Cockayne A, Minton NP. Importance of toxin A, toxin B, and CDT in virulence of an epidemic Clostridium difficile strain. J Infect Dis. 2014;209(1):83–6. Scholar
  16. 16.
    Aslam S, Hamill RJ, Musher DM. Treatment of Clostridium difficile-associated disease: old therapies and new strategies. Lancet Infect Dis. 2005;5(9):549–57. Scholar
  17. 17.
    Clements AC, Magalhães RJ, Tatem AJ, Paterson DL, Riley TV. Clostridium difficile PCR ribotype 027: assessing the risks of further worldwide spread. Lancet Infect Dis. 2010;10(6):395–404. Scholar
  18. 18.
    Crogan NL, Evans BC. Clostridium difficile: an emerging epidemic in nursing homes. Geriatr Nurs. 2007;28(3):161–4. Scholar
  19. 19.
    Pépin J, Routhier S, Gagnon S, Brazeau I. Management and outcomes of a first recurrence of Clostridium difficile-associated disease in Quebec, Canada. Clin Infect Dis. 2006;42(6):758–64. Scholar
  20. 20.
    Pépin J, Saheb N, Coulombe M, et al. Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec. Clin Infect Dis. 2005;41(9):1254–60. Scholar
  21. 21.
    Chopra T, Goldstein EJC. Clostridium difficile infection in long-term care facilities: a call to action for antimicrobial stewardship. Clin Infect Dis. 2015;60(Suppl 2):S72–6. Scholar
  22. 22.
    Laffan AM, Bellantoni MF, Greenough WB, Zenilman JM. Burden of Clostridium difficile-associated diarrhea in a long-term care facility. J Am Geriatr Soc. 2006;54(7):1068–73.,url,cookie,uid&db=ccm&AN=106336610&site=ehost-live&scope=site. doi:
  23. 23.
    Dancer SJ, Kirkpatrick P, Corcoran DS, Christison F, Farmer D, Robertson C. Approaching zero: temporal effects of a restrictive antibiotic policy on hospital-acquired Clostridium difficile, extended-spectrum β-lactamase-producing coliforms and meticillin-resistant Staphylococcus aureus. Int J Antimicrob Agents. 2013;41(2):137–42. Scholar
  24. 24.
    Anderson DJ, Gergen MF, Smathers E, et al. Decontamination of targeted pathogens from patient rooms using an automated ultraviolet-C-emitting device. Infect Control Hosp Epidemiol. 2013;34(5):466–71. Scholar
  25. 25.
    Vonberg R, Kuijper EJ, Wilcox MH, et al. Infection control measures to limit the spread of Clostridium difficile. Clin Microbiol Infect. 2008;14(Suppl 5):2–20. Scholar
  26. 26.
    Khanafer N, Voirin N, Barbut F, Kuijper E, Vanhems P. Hospital management of Clostridium difficile infection: a review of the literature. J Hosp Infect. 2015;90(2):91–101. Scholar
  27. 27.
    Luciano JA, Zuckerbraun BS. Clostridium difficile infection: prevention, treatment, and surgical management. Surg Clin N Am. 2014;94(6):1335–49. Scholar
  28. 28.
    Thomas C, Stevenson M, Riley TV. Antibiotics and hospital-acquired Clostridium difficile-associated diarrhoea: a systematic review. J Antimicrob Chemother. 2003;51(6):1339–50. Scholar
  29. 29.
    Bagdasarian N, Rao K, Malani PN. Diagnosis and treatment of Clostridium difficile in adults: a systematic review. JAMA. 2015;313(4):398–408. Scholar
  30. 30.
    Feazel LM, Malhotra A, Perencevich EN, Kaboli P, Diekema DJ, Schweizer ML. Effect of antibiotic stewardship programmes on Clostridium difficile incidence: a systematic review and meta-analysis. J Antimicrob Chemother. 2014;69(7):1748–54. Scholar
  31. 31.
    Slimings C, Riley TV. Antibiotics and hospital-acquired Clostridium difficile infection: update of systematic review and meta-analysis. J Antimicrob Chemother. 2014;69(4):881–91. Scholar
  32. 32.
    Nelson RL, Kelsey P, Leeman H, et al. Antibiotic treatment for Clostridium difficile-associated diarrhea in adults. Cochrane Database Syst Rev.
  33. 33.
    Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. 2007;45(3):302–7. Scholar
  34. 34.
    Johnson SH, Bettin SR, Quick KM, Clabots JN, Peterson CR, Gerding LR, Dale N. Treatment of asymptomatic Clostridium difficile carriers (fecal excretors) with vancomycin or metronidazole. A randomized, placebo-controlled trial. Ann Intern Med. 1992;117:297–302.CrossRefPubMedGoogle Scholar
  35. 35.
    Kim JH, Muder RR. Clostridium difficile enteritis: a review and pooled analysis of the cases. Anaerobe. 2011;17(2):52–5. Scholar
  36. 36.
    O’Horo JC, Jindai K, Kunzer B, Safdar N. Treatment of recurrent Clostridium difficile infection: a systematic review. Infection. 2014;42(1):43–59.CrossRefPubMedGoogle Scholar
  37. 37.
    Goldberg EJ, Bhalodia S, Jacob S, et al. Clostridium difficile infection: a brief update on emerging therapies. Am J Health Syst Pharm. 2015;72(12):1007–12. Scholar
  38. 38.
    Cornely OA, Miller MA, Louie TJ, Crook DW, Gorbach SL. Treatment of first recurrence of Clostridium difficile infection: fidaxomicin versus vancomycin. Clin Infect Dis. 2012;55(Suppl 2):S154–61. Scholar
  39. 39.
    Louie TJ, Miller MA, Mullane KM, et al. Fidaxomicin versus vancomycin for Clostridium difficile infection. N Engl J Med. 2011;364(5):422–31. Scholar
  40. 40.
    Chahine EB, Sucher AJ, Mantei K. Fidaxomicin: a novel macrolide antibiotic for Clostridium difficile infection. Consult Pharm. 2014;29(9):614–24. Scholar
  41. 41.
    Zanella Terrier MC, Simonet ML, Bichard P, Frossard JL. Recurrent Clostridium difficile infections: the importance of the intestinal microbiota. World J Gastroenterol. 2014;20(23):7416–23. Scholar
  42. 42.
    Cammarota G, Ianiro G, Gasbarrini A. Fecal microbiota transplantation for the treatment of Clostridium difficile infection: a systematic review. J Clin Gastroenterol. 2014;48(8):693–702. Scholar
  43. 43.
    Gough E, Shaikh H, Manges AR. Systematic review of intestinal microbiota transplantation (fecal bacteriotherapy) for recurrent Clostridium difficile infection. Clin Infect Dis. 2011;53(10):994–1002. Scholar
  44. 44.
    Kassam Z, Lee CH, Yuan Y, Hunt RH. Fecal microbiota transplantation for Clostridium difficile infection: systematic review and meta-analysis. Am J Gastroenterol. 2013;108(4):500–8. Scholar
  45. 45.
    Li YT, Cai HF, Wang ZH, Xu J, Fang JY. Systematic review with meta-analysis: long-term outcomes of faecal microbiota transplantation for Clostridium difficile infection. Aliment Pharmacol Ther. 2016;43(4):445–57. Scholar
  46. 46.
    Petrof EO, Khoruts A. From stool transplants to next-generation microbiota therapeutics. Gastroenterology. 2014;146(6):1573–82. Scholar
  47. 47.
    Rao K, Young VB. Fecal microbiota transplantation for the management of Clostridium difficile infection. Infect Dis Clin N Am. 2015;29(1):109–22. Scholar
  48. 48.
    van Nood E, Vrieze A, Nieuwdorp M, et al. Duodenal infusion of donor feces for recurrent Clostridium difficile. N Engl J Med. 2013;368(5):407–15. CrossRefPubMedGoogle Scholar
  49. 49.
    Pakyz AL, Moczygemba LR, VanderWielen LM, Edmond MB. Fecal microbiota transplantation for recurrent Clostridium difficile infection: the patient experience. Am J Infect Control. 2016;44(5):554–9. Scholar
  50. 50.
    Ferrada P, Velopulos CG, Sultan S, et al. Timing and type of surgical treatment of Clostridium difficile-associated disease: a practice management guideline from the eastern association for the surgery of trauma. J Trauma Acute Care Surg. 2014;76(6):1484–93. CrossRefPubMedGoogle Scholar
  51. 51.
    Seder CW, Villalba MR, Robbins J, Ivascu FA, Carpenter CF, Dietrich M. Early colectomy may be associated with improved survival in fulminant Clostridium difficile colitis: an 8-year experience. Am J Surg. 2009;197(3):302–7. Scholar
  52. 52.
    Halabi WJ, Nguyen VQ, Carmichael JC, Pigazzi A, Stamos MJ, Mills S. Clostridium difficile colitis in the united states: a decade of trends, outcomes, risk factors for colectomy, and mortality after colectomy. J Am Coll Surg. 2013;217(5):802–12. Scholar
  53. 53.
    Sailhamer EA, Carson K, Chang Y, et al. Fulminant Clostridium difficile colitis: Patterns of care and predictors of mortality. Arch Surg. 2009;144(5):433–9; discussion 439. doi:
  54. 54.
    Ali SO, Welch JP, Dring RJ. Early surgical intervention for fulminant pseudomembranous colitis. Am Surg. 2008;74(1):20–6.PubMedGoogle Scholar
  55. 55.
    Longo WE, Mazuski JE, Virgo KS, Lee P, Bahadursingh AN, Johnson FE. Outcome after colectomy for Clostridium difficile colitis. Dis Colon Rectum. 2004;47(10):1620–6.CrossRefPubMedGoogle Scholar
  56. 56.
    Hall JF, Berger D. Outcome of colectomy for Clostridium difficile colitis: a plea for early surgical management. Am J Surg. 2008;196(3):384–8. Scholar
  57. 57.
    Lipsett PA, Samantaray DK, Tam ML, Bartlett JG, Lillemoe KD. Pseudomembranous colitis: a surgical disease? Surgery. 1994;116(3):491–6.PubMedGoogle Scholar
  58. 58.
    Neal MD, Alverdy JC, Hall DE, Simmons RL, Zuckerbraun BS. Diverting loop ileostomy and colonic lavage: an alternative to total abdominal colectomy for the treatment of severe, complicated Clostridium difficile associated disease. Ann Surg. 2011;254(3):423–7; discussion 427. doi:

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.VCU Surgery Trauma, Critical Care and Emergency SurgeryRichmondUSA

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