Clostridium Difficile Flashcards
Clostridium Difficile
Clostridium difficile
Clostridium difficile is a Gram positive rod often encountered in hospital practice. It produces an exotoxin which causes intestinal damage leading to a syndrome called pseudomembranous colitis. Clostridium difficile develops when the normal gut flora are suppressed by broad-spectrum antibiotics. Clindamycin is historically associated with causing Clostridium difficile but the aetiology has evolved significantly over the past 10 years. Second and third generation cephalosporins are now the leading cause of Clostridium difficile.
Features diarrhoea abdominal pain a raised white blood cell count is characteristic if severe toxic megacolon may develop
Diagnosis is made by detecting Clostridium difficile toxin (CDT) in the stool
Management
first-line therapy is oral metronidazole for 10-14 days
if severe or not responding to metronidazole then oral vancomycin may be used
for life-threatening infections a combination of oral vancomycin and intravenous metronidazole should be used
Clostridium Difficile Colitis: Example Question
A 84-year-old lady is admitted to the Emergency Department from her nursing home with diarrhoea, abdominal pain and fever. Her symptoms started around 2 days ago and have been getting progressively worse. She is now opening her bowels every other hour and is complaining of severe ‘cramp’ in her lower abdomen. Her past medical history includes hypertension, ischaemic heart disease, hypothyroidism and recent treatment for suspected pyelonephritis.
On examination she is diffusely tender across the lower abdomen. Her pulse is 90/min, blood pressure 100/60 mmHg and temperature 37.4ºC.
Bloods show the following:
Hb 11.1 g/dl Na+ 144 mmol/l Platelets 365 * 109/l K+ 4.6 mmol/l WBC 25.2 * 109/l Urea 10.6 mmol/l Creatinine 99 µmol/l CRP 86 mg/l
The surgeons request an abdominal film and later a CT abdomen:
SEE PASSMED AXR CT C-DIFF COLITIS
What is the most likely diagnosis?
Perinephric abscess Ischaemic colitis Acute diverticulitis Metastatic colorectal cancer > Clostridium difficile colitis
The clues to Clostridium difficile colitis in this question include
age of patient
high white cell count
profuse nature of diarrhoea
recent antibiotic use for pyelonephritis (likely to have been co-amoxiclav or ciprofloxacin)
imaging findings (see below)
On the abdominal film note the loss of bowel wall architecture and thumb-printing consistent with colitis. The CT from the same patient is enhanced by oral contrast. There is moderate free fluid in pelvis and peritoneum. The colon is oedematous throughout with enhancing walls, but of normal calibre. The sigmoid colon is smooth and featureless. Small bowel, liver, spleen, kidneys, adrenals and pancreas are normal.
Severe C- Diff Infection: Example Question
A 74-year-old lady presents with non-bloody diarrhoea for five days. She was treated for Clostridium difficile infection two weeks ago. In the last five days, she has experienced six episodes of diarrhoea per day. Her past medical history includes heart failure, lymphoma and type two diabetes mellitus. On examination, her blood pressure is 134/88 mmHg, pulse is 90/min, temperature is 38ºC, respiratory rate is 16/min and oxygen saturation is 97% on air. She is slightly tender in the left lower quadrant. There are no signs of peritonism and bowel sound is normal. Stool culture result shows positive for glutamate dehydrogenase and toxin enzyme immunoassay. Which of the following drug should be used?
Oral metronidazole Intravenous vancomycin Intravenous metronidazole > Oral fidaxomicin Intravenous fluid and paracetamol
‘For severe infection in patients with multiple co-morbidities who are receiving treatment with other antibacterials, or for second or subsequent episode of infection, fidaxomicin can replace vancomycin’
Source:BNF
Oral instead of intravenous vancomycin is used in the treatment of Clostridium difficile infection.
Omeprazole Induced C-Diff! Example Question
A 60-year-old man presented to the Emergency Department with profuse, foul smelling diarrhoea, abdominal pain and fever.
His past medical history included hypertension, gout and osteoarthritis. His bowel habits are usually regular and there has been no recent change. Two weeks ago he underwent an endoscopy for dyspepsia and was diagnosed with gastritis. He was currently taking amlodipine 5mg, omeprazole 20mg, simvastatin 20mg, salbutamol inhaler one puff as required. He had no known drug allergies. He recently returned from a business trip to Paris.
On examination he was unwell with a heart rate of 110 beats/min and regular, a blood pressure of 100/60 mmHg, oxygen saturations of 96% on air and a temperature of 38ºC. He was peripherally shut down with a capillary refill time of 3 seconds. Abdominal examination revealed and distended and diffusely tender abdomen with guarding.
Initial bloods showed:
Na+ 140 mmol/L K+ 5.0 mmol/L Urea 10 mmol/L Creatinine 130 mmol/L Hb 13.0 g/dL WBC 20.0 x10^9/L Neutrophils 89% LFTs Normal
Abdominal X-ray showed a loss of bowel wall architecture and thumb-printing consistent. Erect chest x-ray showed clear lung fields with no air under the diaphragm.
What is the most likely cause of his symptoms?
Salmonellosis Inflammatory bowel disease Ischaemic colitis Diverticulitis > Omeprazole-induced Clostridium difficile infection
Proton pump inhibitors have been associated with Clostridium difficile infection and subsequent development of pseudomembranous colitis. The clues to this diagnosis included the recent omeprazole use, foul smelling diarrhoea, raised white cell count and abdominal film findings.
The patient is clearly unwell and will require adequate resuscitation before further investigation to confirm the diagnosis.
Diverticulitis can present with abdominal pain and diarrhoea but the clue here is the profuse foul smelling diarrhoea characteristic of Clostridium difficile infection.
Salmonellosis is unlikely as there is nothing from the history to suggest exposure to the bacterium.
Ischaemic colitis typically presents in the elderly with abdominal pain and often bloody diarrhoea.
Inflammatory bowel disease can present similarly but one would expect to have seen a change in bowel habit prior to this acute episode.
Pseudomembranous Colitis - Example Question
A 70 year-old man, who is currently an inpatient after having a hip replacement develops urosepsis.
His past medical history includes ulcerative colitis and ischaemic heart disease. He is commenced on high-dose intravenous cephalosporin and gentamicin and after five days feels better with his observations returning to normal. However, on the fifth day he develops left-sided abdominal tenderness and diarrhoea. Sigmoidoscopy reveals yellow plaques. What is the most likely diagnosis?
Campylobacter infection Ulcerative colitis flare-up > Pseudomembranous colitis Osmotic diarrhoea Diverticulitis
Considering this patient has finished a course of high dose IV cephalosporins, his most likely diagnosis is pseudomembranous colitis. The most common cause of this is clostridium difficile infection, which can present on sigmoidoscopy with yellow plaques on the intraluminal wall of the colon.
C-Diff = ORAL VANC - Example Question
A 60-year-old male presents with one week history of non-bloody diarrhoea and mild abdominal pain. In average, diarrhoea occurs four times a day. Two weeks ago, he was given co-amoxiclav to treat leg cellulitis. His temperature is 38.4ºC, blood pressure is 130/66 mmHg, heart rate is 90/min, oxygen saturation is 96% on air and respiratory rate is 20/min. On examination, he is tender on palpation of the left iliac fossa. There are no signs of peritonism and bowel sound is normal. He has been taking metronidazole for 4 days without any clinical improvement.
CRP 140mg/L
WBC 20 x 10^9/L
Which of the following drug should be started while awaiting for the stool culture?
Intravenous metronidazole > Oral vancomycin Intravenous vancomycin Intravenous co-amoxiclav Oral ciprofloxacin
The most likely cause for this patient’s symptoms is Clostridium difficile infection due to the recent use of co-amoxiclav.
‘For second or subsequent episode of infection, for severe infection, for infection not responding to metronidazole, or in patients intolerant of metronidazole, oral vancomycin’
Source:BNF
C-Diff - Example Question
70 year old male presents with 3 days of vomiting and profuse watery diarrhoea, up to 6 times a day, with abdominal pain and a fever. He denies any haematemsis or malaena. He returned from a holiday to India 6 weeks ago and also visited his niece in the Lake District, where he had a barbecue about a week prior. He has minimal medical history except a ‘cough and cold’ treated by his GP with 3 days of oral augmentin last week. His past medical history include hypertension, gastric reflux and type 2 diabetes mellitus, for which he takes metformin, ramipril and lansoprazole. On examination, abdomen generally tender and distended, resonant to percussion. Bowel sounds are absent. Stool cultures were initially sent three days ago but the results are still awaited, the laboratory reports that the sample has been lost. A flexible sigmoidoscopy was performed, with the report stating yellow membranes in an inflamed sigmoid colon. What is the most likely diagnosis?
Bacillus cereus infection from undercooked barbecue meats Giardiasis > Clostridium difficile infection Diverticulitis E Coli 0157 gastroenteritis
Fever, abdominal pain, diarrhoea in the context of recent antibiotic use and lansoprazole should raise suspicion for clostridum difficile infection. The colonscopic description of yellow membranes is suggestive of pseudomembranous colitis as a result of exudates and cell debris from C diff infection. Bacillus cereus usually occurs within 24 hours, E Coli within 72 hours (with bloody stool) and giardiasis within 3 weeks. Diverticulitis would be seen on flexible sigmoidoscopy.
FIDAXOMICIN
‘For severe infection in patients with multiple co-morbidities who are receiving treatment with other antibacterials, or for second or subsequent episode of infection, fidaxomicin can replace vancomycin’
C-Diff Colitis - AXR and Colonoscopy
Abdominal X-ray showed a loss of bowel wall architecture and thumb-printing
Can present on sigmoidoscopy with yellow plaques on the intraluminal wall of the colon.
Omeprazole induced C-Diff Colitis
Proton pump inhibitors have been associated with Clostridium difficile infection and subsequent development of pseudomembranous colitis.
