Case Presentation: Clostridium Difficile

Case Presentation
Clostridium Difficile
Patient G.R.
- 88 yo WM
- Previous hospital admission for
pneumonia treated with
piperacillin/tazobactam
- Admitted to KMC on 1/17/02 for scrotal
edema and diarrhea.
Physical Exam
WD thin, frail confused WM

A & O to Person Only Mild Tenderness in RLQ
Scrotal Edema Without erythema
Ht: 152.4cm
Wt: 40 Kg
IBW: 52 Kg
CrCl: 21ml/min
U/S Revealed Cysts in Scrotum W/o Testicular

Involvement. No Evidence of Infection.
G.R.’S Meds:
Zosyn 2.5gm IV Q 6h
Tylenol 10gr Po Q 4 H prn
Phenergan 12.5mg IV Q 6 H prn
IV Fluids With KCl at 120ml/hr
Coumadin 2.5mg Po qd
Lanoxin 0.25mg Po qd
ASA 81mg Po qd
G.R.’S Meds: (cont’d)
Atenolol 50mg Po qd
Cardizem(diltiazem) IV for HR > 100
Ensure Plus 1 can tid
Vancomycin 125mg Po qid *
Bacid 1 Capsule Po tid*
Questran(cholestyramine) 1 scoopful*
Lactinex 1 tablet po bid*
Flagyl(metronidazole) 250mg po tid*
*= Treatment related therapy
Cultures/Studies
Stool Toxin Positive for C. difficile 1/19/02

Urine Cx – negative 1/18/02
Treatment Changes
-Discontinue Zosyn
-Change Flagyl to 250mg po qid
-Discontinue Vancomycin po
-Discontinue Questran
-Discontinue Bacid
Summary
The patient’s diarrhea gradually improved over a

period of several days and the patient was
discharged to an ECF
Antibiotic-Associated Diarrhea
-AAD is defined as otherwise unexplained diarrhea

that occurs in association with the administration of
antibiotics.
AAD Frequency of Complication
• 10-25% of pts treated with amoxicillin/clavulanate.
• 15-20% of pts treated with cefixime.
• 2-5% of those treated with other cephalosporins,

quinolones, azithromycin, clarithromycin,
erythromycin, and tetracycline.
• 5-10% of pts treated with ampicillin.
• 1 in 10 to 1 in 10,000 treated w/ clindamycin- in hospital
Spectrum of Findings
• Nuisance diarrhea
• Colitis
– Abdominal cramping
– Fever
– Leukocytosis
– Fecal leukocytosis
– Hypoalbuminemia
– Colonic thickening on CT and endoscopic changes
Colitis
www.gicare.com/pated/ eicnclcc.htm
Clostridium difficile
-Gm +, spore-forming anaerobic bacillus.
-accounts for approx. 25% of the cases of AAD
-accounts for the majority of cases of colitis associated with

antibiotic therapy.
-Causes 300,000 to 3,000,000 cases of diarrhea and colitis

in the U.S. every year
Bartlett J, Antibiotic-Associated Diarrhea, N Engl J Med, Vol. 346, No. 5, Jan. 31, 2002
-Other Causes of AAD
-Other enteric pathogens
-Direct effects of antimicrobial agents
-Reduced fecal flora
-Other enteric pathogens

-salmonella,
-C. perfringens type A,
-Staphylococcus aureus, and possibly
-C. albicans overgrowth
-Other Causes of AAD

-FQ-resistant disease
-Drug effects independent of motility
-Effects of non-antibiotic drugs

- Laxatives - Antacids
- Contrast Agents - Antiarrhythmics
- NSAIDs - Cholinergic Agents
- Products containing lactose or sorbitol
Pathogenesis
Major Risk Factors for C. difficile infection:
1. Advanced age
2. Hospitalization
3. Exposure to antibiotics
Clostridium Difficile
- Antibiotics most frequently associated with the infection

are:
- Clindamycin
- Ampicillin
- Amoxicillin
- Cephalosporins
Epidemiology:
-Most cases occur in hospitals or LTC (rate of 25-60 per

100,000 occupied bed-days)
-incidence in the OP setting is 7.7 cases per 100,000

person-years
Pathogenesis
-Toxinogenic C. difficile is isolated from stool specimens in
only 0% to 3% of healthy adults.
-During hospitalization, colonization frequently occurs.
-C. difficile forms spores that persist in the environment

for years and contamination by C. difficile is common in
hospitals and LTC facilities
Pathogenesis
- Clinical symptoms develop in only about 1/3 of colonized

patients, and
- asymptomatic colonization with C difficile may be

associated with a decreased risk for development of C.
difficile-associated diarrhea.
Pathogenesis
-Two factors have recently been shown to increase the

probability of symptomatic disease in patients who
acquire C difficile colonization in the hospital:
• 1. Severity of other illnesses
• 2. Reduced levels of serum IgG antibody to toxin A.
Pathogenesis
-Clinically significant strain of C. difficile that cause

disease produce 2 protein exotoxins, toxin A, and toxin B.
-Full tissue damage requires the action of both toxins

Clinical Manifestations
-diarrhea
-colitis without pseudomembranes
-pseudomembranous colitis
-fulminant colitis
-hyperpyrexia
-Mild to moderate CDAD is usually accompanied by lower

abdominal cramping pain but no systemic symptoms or
physical findings.
-Moderate to severe colitis usually presents with profuse

diarrhea, abdominal distention with pain, and, in some
cases, occult colonic bleeding.
Fulminant Colitis- develops in approximately in 1% to 3%

of patients
Others: hyperpyrexia, chronic diarrhea, and

hypoalbuminemia with anasarca.
C difficile may occasionally complicate idiopathic
inflammatory bowel disease.
A reactive arthritis occurring 1-4 weeks after C.
difficile colitis develops in some patients.
Diagnosis
-Non-specific laboratory abnormalities: leukocytosis with

left shift and fecal leukocytes in about 50-60 % of cases.
-Avg peripheral WBC is 12 x 109/L to 20 x 109/L.
- Gram staining of fecal specimens are no value
- Anaerobic culture of stool (takes 2-3 days and does not

distinguish between toxinogenic from nontoxinogenic
strains)
Diagnosis
-Most sensitive and specific test is a tissue culture assay for

the cytotoxicity of toxin B (takes 1-3 days and requires
tissue culture facilities)- GOLD STANDARD
-ELISA- detects toxin A and/or B in stool. Rapid

turnaround.
-Stool samples- If results are negative, 1-2 additional

samples should be sent. If first is positive, no further
specimens are required.
Bartlett J, Antibiotic-Associated Diarrhea, N Engl J Med, Vol. 346, No. 5,
Jan. 31, 2002
Treatment
Table 4. General Guidelines for the Management
of Clostridium difficile–Associated Diarrhea*
1. Isolate the patient.

2. Educate personnel to use gloves when in contact with
patient and for the handling of bodily substances.
3. If possible, discontinue inciting antibiotic therapy and
avoid anti-peristaltic and opiate drugs.
4. Confirm the diagnosis with a test for C difficile toxin. If
the results of the first specimen are negative and diarrhea
persists, 1 or 2 additional stool samples should be sent.
Treatment
5. If clinically indicated (moderate or severe diarrhea, systemic

symptoms, significant leukocytosis, etc), consider antimicrobial
treatment against C difficile. If the clinical suspicion is high and the
patient is severely ill, empiric antimicrobial treatment may be
started awaiting laboratory confirmation.
6. Oral metronidazole (250 mg 4 times per day or 500 mg 3 times per
day) for 10-14 d is usually adequate.
7. Oral vancomycin hydrochloride (125 mg 4 times per day) for 10-
14 d is indicated for those who cannot tolerate oral metronidazole,
those in whom metronidazole therapy fails, pregnant patients, and,
perhaps, severely ill patients.
Treatment
8. The first relapse/recurrence of C difficile colitis can be treated

with another 10- to 14-d course of oral metronidazole or vancomycin
9. Therapy of patients with multiple relapses of C difficile colitis has
not been examined by randomized, prospective, controlled clinical
trials. A tapering course of metronidazole or vancomycin for 4-6 wk
has been used.
* Adapted from Johnson and Gerding and Fekety.
Mylonakis E, et al, Clostridium difficile-Associated Diarrhea A Review. Archives

of Internal Medicine, Vol. 161, No. 4, Feb. 26, 2001
Treatment
Tapering Schedule
Week Vanco dose
1 125mg qid
2 125mg bid
3 125mg qd
4 125mg q.o.d.
5&6 125mg q 3 d
Mylonakis E, et al, Clostridium difficile-Associated Diarrhea A Review. Archives
of Internal Medicine, Vol. 161, No. 4, Feb. 26, 2001
Treatment
Other Approaches
-Vancomycin with cholestyramine resin (4gm BID)

- Oral Vancomycin 125mg qid, oral rifampin 600mg
bid x 7 days
- Saccharomyces cerevisiae (Brewer’s Yeast)_
- IgG infusion at dose of 200 to 300mg/kg
Bartlett J, Antibiotic-Associated Diarrhea, N Engl J Med, Vol. 346, No. 5, Jan. 31, 2002

Case Presentation: Clostridium Difficile

Uploaded by

Copyright:

Available Formats

Case Presentation: Clostridium Difficile

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Case Presentation: Clostridium Difficile

Uploaded by

Copyright:

Available Formats

Case Presentation

WD thin, frail confused WM

U/S Revealed Cysts in Scrotum W/o Testicular

Stool Toxin Positive for C. difficile 1/19/02

The patient’s diarrhea gradually improved over a

-AAD is defined as otherwise unexplained diarrhea

• 10-25% of pts treated with amoxicillin/clavulanate.

• 15-20% of pts treated with cefixime.

• 2-5% of those treated with other cephalosporins,

-Gm +, spore-forming anaerobic bacillus.

-accounts for approx. 25% of the cases of AAD

-accounts for the majority of cases of colitis associated with

-Causes 300,000 to 3,000,000 cases of diarrhea and colitis

-Other enteric pathogens

-Other Causes of AAD

-Effects of non-antibiotic drugs

Major Risk Factors for C. difficile infection:

- Antibiotics most frequently associated with the infection

-Most cases occur in hospitals or LTC (rate of 25-60 per

-incidence in the OP setting is 7.7 cases per 100,000

-During hospitalization, colonization frequently occurs.

-C. difficile forms spores that persist in the environment

- Clinical symptoms develop in only about 1/3 of colonized

- asymptomatic colonization with C difficile may be

-Two factors have recently been shown to increase the

-Clinically significant strain of C. difficile that cause

-Full tissue damage requires the action of both toxins

-Mild to moderate CDAD is usually accompanied by lower

-Moderate to severe colitis usually presents with profuse

Fulminant Colitis- develops in approximately in 1% to 3%

Others: hyperpyrexia, chronic diarrhea, and

-Non-specific laboratory abnormalities: leukocytosis with

-Avg peripheral WBC is 12 x 109/L to 20 x 109/L.

- Gram staining of fecal specimens are no value

- Anaerobic culture of stool (takes 2-3 days and does not

-Most sensitive and specific test is a tissue culture assay for

-ELISA- detects toxin A and/or B in stool. Rapid

-Stool samples- If results are negative, 1-2 additional

1. Isolate the patient.

5. If clinically indicated (moderate or severe diarrhea, systemic

8. The first relapse/recurrence of C difficile colitis can be treated

Mylonakis E, et al, Clostridium difficile-Associated Diarrhea A Review. Archives

-Vancomycin with cholestyramine resin (4gm BID)

You might also like