Updated: 12/19/2019

Clostridium difficile (C. diff)

Topic
Review Topic
0
0
0%
0%
Questions
5 5
0
0
0%
0%
Evidence
4 4
0
0
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
 

Please rate topic.

Average 4.8 of 6 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (5)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
Calculator

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

You have 100% on this question.
Just skip this one for now.

(M2.ID.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? Review Topic | Tested Concept

QID: 103516
1

Ciprofloxacin

3%

(1/30)

2

Ciprofloxacin and metronidazole

10%

(3/30)

3

Metronidazole

40%

(12/30)

4

No treatment indicated

43%

(13/30)

5

Vancomycin

0%

(0/30)

M2 D

Select Answer to see Preferred Response

Evidences (6)
Topic COMMENTS (7)
Private Note