Updated: 2/27/2021

Clostridium difficile (C. diff)

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Snapshot
  • A 44-year-old woman presents to the emergency room for watery diarrhea for 3 days. She was recently admitted to the hospital for a urinary tract infection and discharged to finish a course of ampicillin. She completed this course 2 weeks ago. She reports seeing occasional blood in her diarrhea, but that it has mostly been watery. She also reports having anorexia, malaise, and cramping abdominal pain. On physical exam, she is dehydrated and has tenderness to palpation in the abdomen. She is found with a marked leukocytosis and started on fluids as well as oral vancomycin.
Introduction
  • Classification
    • Clostridium difficile 
      • anaerobic gram + rod
      • produces 2 toxins that bind to intestinal mucosal cells
      • forms heat-resistant spores
  • Epidemiology
    • incidence
      • common
    • risk factors
      • recent antibiotics use
        • clindamycin 
        • ampicillin
        • cephalosporins
        • fluoroquinolones
      • proton-pump inhibitors
      • recent hospitalization
      • advanced age
  • Pathogenesis
    • causes a pseudomembranous colitis and diarrhea 
      • characterized by yellow-white plaques in intestinal mucosa
    • toxin A is an enterotoxin that binds to the intestinal brush border
    • toxin B is a cytotoxin and depolymerizes actin, disrupting the cytoskeleton
  • Prognosis
    • relapse occurs in ~20% of patients
Presentation
  • Symptoms
    • crampy abdominal pain
    • anorexia
    • malaise
    • diarrhea
      • typically watery diarrhea
      • occasionally may be bloody but without frank blood
  • Physical exam
    • fever
    • dehydration
    • abdominal tenderness to palpation
    • rebound tenderness in severe cases
Imaging
  • Abdominal radiography
    • indications
      • if toxic megacolon is suspected
      • for quick diagnosis and assess for early intervention
    • findings
      • dilated colon
  • Sigmoidoscopy/colonoscopy
    • indication
      • if laboratory evaluation is unclear
      • not always necessary
    • findings
      • pseudomembranes on intestinal mucosa
  • Abdominal computed tomography (CT)
    • indication
      • suspicion for pseudomembranous colitis
    • findings
      • marked thickening of the colonic wall
      • irregularity of bowel wall
      • pericolonic stranding
Studies
  • Labs
    • ↑ white blood cells
    • ↓ hypoalbuminemia
    • ↑ lactate
    • diagnostic tests of the stool
      • polymerase chain reaction for the organism
      • detection of toxin   
      • + fecal leukocytes
  • Making the diagnosis
    • based on clinical presentation and stool studies
Differential
  • Ulcerative colitis
    • distinguishing factors
      • typically presents with bloody diarrhea
      • can also present with dermatologic manifestations such as erythema nodosum
  • Crohn disease
    • distinguishing factors
      • can be bloody or nonbloody
      • can present with fistulas
      • can also present with dermatologic manifestations such as erythema nodosum
Treatment
  • Management approach
    • 10-day course of antibiotics
    • discontinue inciting antibiotics or other drugs 
  • Medical
    • oral vancomycin  
      • indications
        • first line
        • severe cases
    • fidaxomicin
      • indication
        • recurrent cases
    • oral metronidazole
      • indications 
        • used as an alternative if vancomycin or fidaxomicin are not available
        • used in addition to vancomycin if patients are refractory to monotherapy
        • contraindicated in the elderly
    • fecal microbiota transplant
      • indication
        • recurrent cases
Complications
  • Colonic perforation
    • occurs in small percentage of patients
  • Toxic megacolon
    • occurs in small percentage of patients

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(M2.ID.15.26) A 33-year-old man presents to the emergency room for diarrhea. He states it is profuse and watery and has not been improving over the past week. He is generally healthy; however, he was recently hospitalized during spring break and treated for alcohol intoxication and an aspiration pneumonia. While on spring break, the patient also went camping and admits eating undercooked chicken and drinking from mountain streams. His temperature is 100.5°F (38.1°C), blood pressure is 111/74 mmHg, pulse is 110/min, respirations are 16/min, and oxygen saturation is 98% on room air. Physical exam is notable for a fatigued appearing man. His abdomen is non-tender. Which of the following is the best management of this patient?

QID: 103516
1

Ciprofloxacin

3%

(1/35)

2

Ciprofloxacin and metronidazole

9%

(3/35)

3

Metronidazole

40%

(14/35)

4

No treatment indicated

43%

(15/35)

5

Vancomycin

3%

(1/35)

M 7 E

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