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Clostridium Difficile Infection - Causes, Symptoms and Treatment

Definition:

Clostridium difficile is a gram-positive anaerobic bacterium most often associated with antibiotic-associated colitis and diarrhea. Symptoms ranging from asymptomatic carrier states to severe pseudomembranous colitis are caused by exotoxins produced by the microbe: toxin A (an enterotoxin) and toxin B (a cytotoxin). Complications include electrolyte abnormalities, hypovolemic shock, anasarca (caused by hypoalbuminemia), sepsis, and hemorrhage. Rarely, death may result.

Causes

Although Clostridium difficile Infection can be caused by almost any antibiotic that disrupts the intestinal flora, it's classically associated with clindamycin use. Additional factors that alter normal intestinal flora include enemas and intestinal stimulants. Patients at high risk for this disorder include those taking many kinds of antibiotics or antineoplastic agents that have antibiotic activity; candidates for abdominal surgery; immunocompromised individuals; pediatric patients (infections are common in day-care centers); and nursing-home patients.

Clostridium difficile may be transmitted very easily from one person to other through contaminated hands of personnel (most common), or indirectly through contaminated equipment such as bedpans, urinals, call bells, rectal thermometers, and NG tubes, and surfaces of bed rails, floors, and toilet seats.

Signs and Symptoms

Risk of Clostridium difficile infection begins 1 to 2 days after antibiotic therapy is started and persists for as long as 2 to 3 months after the last dose. The patient may be asymptomatic, or may present any of the following symptoms: soft, unformed stool or watery diarrhea (more than 3 evacuations in 24 hours) that may be foul-smelling or grossly bloody; abdominal pain, cramping or tenderness; and fever. The white blood cell count may be elevated to 20,000/L. In severe cases, toxic megacolon, colonic perforation, and peritonitis develop.

Diagnosis

Clostridium Difficile infection is confirmed by identification of the exotoxins, using one of the following methods:

Cell Cytotoxin Test: Highly sensitive and specific for toxins A and B of Clostridium difficile; results available in 2 days.

Enzyme Immunoassays: Slightly less sensitive than the cell cytotoxin test, but result are obtained in a few hours; specifity is excellent.

Stool Culture: Most sensitive, with 2-day turnround. Nontoxin-producing strains of C. difficile can be easily identified using 3 separate stool samples to test for the presence of the toxin.

Endoscopy (flexible sigmoidoscopy): may be used in patients who present with an acute abdomen but no diarrhea, making it difficult to obtain a stool specimen. If pseudomembranes are seen, treatment for c. difficile is usually initiated.

Treatment

Withdrawing the causative antibiotic (if possible) resolves symptoms in patients who are mildly symptomatic. This is usually the only treatment required,

For more severe cases, metronidazole 250 mg by mouth (PO.) four times daily or 500 mg P.O. three times daily, or vancomycin 125 mg P.O. four times daily for 10 days are effective therapies, with metronidazole being the preferred treatment. Retesting for C. difficile is unnecessary if symptoms resolve.

In 10% to 20% of patients, C. difficile may recur within 14 to 30 days of treatment. Beyond 30 days, it's questionable whether the recurrence is a relapse or reinfection with C. difficile. If metronidazole was the initial treatment, low-dose vancomycin, given 125 mg P.O. four times daily for 21 days, may be effective. Alternatively, give vancomycin (125 mg P.O. four times daily) in combination with rifampin (600 mg P.O. twice daily) for 10 days.

Special Considerations

1)Patients with known or suspect C. difficile diarrhea who are unable to practice good hygiene should be placed in a single room or with other patients with the same infection and no other infections.

2)Follow standard precautions and contact precautions for contact with blood and body fluids for all direct patient contact and contact with the patient's immediate environment. Use good hand-washing technique with antiseptic soap.

3)Reusable equipment must be disinfected before use on another patient.

4)Patients who are asymptomatic, without diarrhea or fecal incontinence for 72 hours, and who are able to practice good hygiene may be transferred out of single rooms.

5)Preventive strategies include careful selection of antibiotic therapy, use of single antibiotics when possible, avoiding antibiotics when they're not absolutely necessary, and limiting the duration of the antibiotic treatment regimen.

6)Because spores of C. difficile are resistant to most commonly used stool disinfectants, the patient's room may be contaminated even after the patient is discharged. The immediate environment must be thoroughly cleaned and disinfected with 0.5% sodium hypochlorite.

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