Clostridium Difficile Enteritis

CLOSTRIDIUM DIFFICILE ENTERITIS Description: Clostridium difficile: A bacterial species found in feces of humans and animals. It colonizes newborn infants, who are spared from toxin induced diarrheal disease. Pathogenic for human beings, guinea pigs, and rabbits; frequent cause of colitis and diarrhea following antibiotic use. Found to be a cause of pseudomembranous colitis and associated with a number of intestinal diseases that are linked to antibiotic therapy; also the chief cause of nosocomial diarrhea. Clostridium difficile enteritis of the small bowel is believed to be less common and has been described sparsely in the literature. The severe case of clostridium difficile enteritis is C. difficile colitis. Clostridium difficile infection commonly manifests as mild-to-moderate diarrhea, occasionally with abdominal cramping. Pseudomembranes, adherent yellowish-white plaques on the intestinal mucosa, occasionally are observed. In rare cases, patients with C difficile infection can present with an acute abdomen and fulminant life-threatening colitis. Approximately 20% of individuals who are hospitalized acquire Clostridium difficile during hospitalization, and more than 30% of these patients develop diarrhea. Thus, C difficile colitis is currently one of the most common nosocomial infections. Clostridium difficile infection primarily occurs in hospitalized patients, causing as many as 3 million cases of diarrhea and colitis per year. It is reported that 7% of patients admitted to a hospital and 28% of patients who were hospitalized had positive cultures for the organism. Approximately one third of these patients developed diarrhea. According to one report, only 20,000 cases per year are diagnosed in outpatients. C difficile infection is more common in elderly people, and old age may promote susceptibility to colonization and disease. While infants and young children frequently harbor C difficile and its toxins, clinical infection is uncommon. Cross-infection by C difficile is common in neonatal units, but neonates do not seem to develop Clostridium difficile associated diarrhea. Complications of C. difficile infections include: Dehydration: Severe diarrhea can lead to a significant loss of fluids and electrolytes. This makes it difficult for your body to function normally and can cause blood pressure to drop to dangerously low levels.
  • Kidney failure: In some cases, dehydration can occur so quickly that kidney function deteriorates (kidney failure).
  • A hole in your large intestine (bowel perforation): This results from extensive damage to the lining of your large intestine. A perforated bowel can spill bacteria from the intestine into your abdominal cavity, leading to a life-threatening infection (peritonitis).
  • Toxic megacolon: In this condition, the colon becomes grossly distended when it's unable to expel gas and stool. Left untreated, your colon can rupture, causing bacteria from the colon to enter your abdominal cavity. A ruptured colon requires emergency surgery and may be fatal.
  • Death: Even mild to moderate C. difficile infections can quickly progress to a fatal disease if not treated promptly.
Symptoms:Clostridium difficile The symptoms may begin hours to days after you become infected. Symptoms may include: Abdominal pain.
  • Diarrhea - acute and severe.
  • Loss of appetite.
  • Vomiting - rare.
Causes and Risk factors: Risk Factors: The majority of Clostridium difficile cases occur in health care settings, where germs spread easily, antibiotic use is common and people are especially vulnerable to infection. In hospitals and nursing homes, C. difficile spreads mainly on the hands of caregivers, but also on cart handles, bedrails, bedside tables, toilets, sinks, stethoscopes, thermometers — even telephones and remote controls. Although people — including children — with no known risk factors have gotten sick from C. difficile, your risk is greatest if you: Are taking or have recently taken antibiotics. The risk goes up if you take broad-spectrum drugs that target a wide range of bacteria, use multiple antibiotics or take antibiotics for a prolonged period.
  • Are 65 years of age or older. The risk of becoming infected with Clostridium difficile is 10 times greater for people age 65 and up compared with younger people.
  • Are or have recently been hospitalized, especially for an extended period.
  • Live in a nursing home or long term care facility.
  • Have a serious underlying illness or a weakened immune system as a result of a medical condition or treatment (such as chemotherapy).
  • Have had abdominal surgery or a gastrointestinal procedure.
  • Have a colon disease such as inflammatory bowel disease or colorectal cancer.
  • Have had a previous C. difficile infection.
Diagnosis: A stool culture may be done to determine the specific type of infection. However, this test may not always identify the bacteria causing the illness. Laboratory studies include: Electrolytes: Dehydration and electrolyte imbalance may accompany severe disease.
  • Albumin: Hypoalbuminemia and anasarca may accompany severe disease.
  • CBC count: Leukocytosis may be present.
Stool assays for C difficile:
  • The stool cytotoxin test has high sensitivity and specificity and is the test of choice. Diarrheal stool is filtered and then added to cultured fibroblasts. A positive test result is the demonstration of a cytopathic effect that is neutralized by specific antiserum. This test result is reported only as positive or negative, it is expensive, and it requires an overnight incubation and a tissue culture facility.
  • Several commercial enzyme immunoassays are now available and provide more rapid results at less cost with reasonable sensitivity and specificity. Because of the lower sensitivity, repeating this test may be necessary in patients in whom the pretest probability of C difficile infection is high and an initial test result is negative.
  • The latex agglutination test cannot be used to detect toxins but instead detects the presence of glutamate dehydrogenase produced by C difficile. The sensitivity of this test is 48-59%, and the specificity is 95-96%. This test is not recommended.
  • Stool cultures are not helpful because nontoxigenic strains of C difficile exist.
Treatment: Mild cases usually need no treatment. Antidiarrheal medication may delay the organism from leaving the digestive tract, and therefore may not be recommended.
  • Rehydration with electrolyte solutions may be necessary if dehydration occurs.
Persons with diarrhea (especially young children) who are unable to drink fluids because of nausea may need medical care and fluids through a vein (intravenous fluids). If you take diuretics and develop diarrhea, you may need to stop taking the diuretic during the acute episode. Do not stop taking any medicine unless told to do so by your health care provider Medicine and medications: In mild cases (ie, patients without fever, abdominal pain, or leukocytosis), cessation of causative antibiotics may be the only treatment necessary. For patients with more severe or persistent diarrhea or evidence of overt colitis, a second course of metronidazole or vancomycin is indicated. Treatment with vancomycin for relapse after metronidazole therapy is not necessary because development of antibiotic resistance is not usually the cause of relapse. Unfortunately, some patients may experience further relapses after antibiotic therapy is again discontinued. DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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