A Hospital Outbreak of Diarrhea Due to an Emerging Epidemic Strain of Clostridium difficile

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Abstract
Clostridium difficile–associated disease (CDAD) is a leading cause of nosocomial diarrhea in the United States,1,2 resulting in more than $1 billion in excess health care costs annually.3 The pathogenicity of C difficile is largely attributed to 2 large cytotoxins, A (TcdA) and B (TcdB), whose production is thought to be controlled in part by a negative regulatory gene, tcdC.4,5 Deletions or other mutations in the tcdC gene are hypothesized to result in increased toxin production by C difficile.6 Also, some strains produce an additional toxin, binary toxin, designated binary toxin CDT, which is tentatively associated with severe disease.7-9 An additional factor that affects the ability of some C difficile strains to become highly prevalent is their acquired resistance to commonly used antimicrobial agents. Clindamycin, cephalosporins, and, more recently, fluoroquinolones have all been implicated in CDAD, presumably through suppression of the normal colonic flora.10-12

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