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Clostridium difficile after antibiotic therapy

Sir, The isolation of Clostridium difficile or detection of its toxin is a well recognized association with diarrhoea in hospital patients, where it accounts for 10-15% of cases of diarrhoea associated with antibiotic treatment.' In contrast, C difficile has only rarely been reported as a cause of diarrhoeal illness in general practice although, given the ubiquity of both the causative bacteria and antibiotic therapy, there is no reason to think it should not also occur.2 The results of all stool samples sent by general practitioners to the Department of Medical Microbiology, Southmead Hospital, Bristol, between August 1992 and April 1993 were reviewed. There were eight patients from whom samples had been sent by general practitioners and in which C difficile toxin was identified using the Premier Kit® (Meridan Diagnostics). Seven of the patients were women and they were aged between 29 and 56 years; the man was aged 79 years. All had recently received a beta lactam antibiotic for a community-acquired infection: (chest infection (five cases), pelvic infection (one), urinary tract infection (one) and sinusitis (one). Three had received coamoxiclav, two ampicillin, two cefixime and one amoxycillin. All had diarrhoea, most commonly occurring within one week after stopping antibiotic therapy but in one case a diagnosis was not made until 42 days later. All recovered from their diarrhoea after being treated with oral metronidazole 400 mg three times a day for 7-10 days. Data from the Avon family health services authority for the period August 1992 to April 1993 showed that amoxycillin was the most commonly prescribed antimicrobial locally (R Grant, personal communication). There were 42 970 prescriptions for amoxycillin (33.7% of all antibiotics), 13 749 for co-amoxiclav (10.8%) and cefixime accounted for 0.5% of prescriptions. The cases presented here illustrate what must be a common problem in general practice. Despite the fact that C difficile is a well-known hospital pathogen we have found only one published report of its association with diarrhoea in the community.2 While most cases of C difficile diarrhoea are mild or moderate, for a proportion of hospital patients infection may lead to more severe outcomes such as bowel perforation or gram-negative shock. Diarrhoea due to C difficile has no particular clinical features and presents like many other enteric pathogens with the exception of a history of antimicrobial use within the previous two months. Beta lactam antibiotics, which disturb the normal bowel flora, were commonly associated with infection in the patients studied here, as has been described in hospital patients.3 Both co-amoxiclav and cefixime were more likely to be associated with C difficile diarrhoea than would be expected from the numbers of prescriptions for these agents. Patients who have diarrhoea and who have recently received antibiotic therapy should have stool samples sent to a microbiology laboratory and a history of antibiotic use should be indicated, or a C difficile toxin test specifically requested.