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  • • Results from antibiotic therapy or alteration in colonic flora

    • Diarrhea with or without gross mucosal abnormalities

    • Caused by Clostridium difficile toxins A and B

    • Also referred to as pseudomembranous colitis

    • Clindamycin, ampicillin, cephalosporins are common inciting antibiotics

    • May progress to toxic megacolon, perforation

    • Symptoms may develop up to 6 weeks following antibiotic treatment

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Epidemiology

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  • • Transmitted in hospital or closed environments

    • Epidemics noted on surgical wards

    • Can be transmitted by health care personnel, making wearing gloves and washing hands essential

    • Infection can be especially severe in immunocompromised patients

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Symptoms and Signs

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  • • Watery, green diarrhea, sometimes bloody

    • Crampy abdominal pain, cramping

    • Vomiting

    • Fever

    • Complications including toxic megacolon or perforation may lead to peritoneal signs

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Laboratory Findings

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  • • Leukocytosis

    • Positive tests for C difficile cytotoxin

    • Positive stool culture

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Imaging Findings

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  • Endoscopy (sigmoidoscopy)

    • -Elevated plaques

      -Pseudomembranes

      -Erythematous, edematous mucosa

    Biopsy

    • -Leukocytes

      -Necrotic epithelium

      -Fibrin

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  • • Malignancy

    • Stricture

    • Ischemic colitis

    • Diverticulitis

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Rule Out

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  • • Other causes of infectious colitis

    • -Amebic

      -Actinomycosis

      -Cytomegalovirus (in immunocompromised patients)

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  • • Sigmoidoscopy/colonoscopy with or without biopsy

    • Stool culture, C difficile cytotoxin

    • WBC count

    • History of antibiotic therapy

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When to Admit

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  • • Dehydration

    • Worsening abdominal pain/distention

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  • • Discontinue inciting antibiotic

    • Oral vancomycin for 7-10 days

    • Oral metronidazole for 7-14 days

    • Avoid antidiarrheal medications

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Surgery

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Indications

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  • • Failure of medical management with worsening clinical course/progression to toxic megacolon, peritonitis, perforation

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Medications

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  • • Oral vancomycin

    • Oral metronidazole

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Treatment Monitoring

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  • • Serial abdominal exams

    • Serial WBC count

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Complications

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  • • Sepsis

    • Colonic dilatation, perforation

    • Hypovolemia/shock

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Prognosis

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  • • Recurrence after treatment is 20%

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Prevention

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  • • Proper hand washing and protective barrier (gown and gloves) with infected patients

    • Discontinue unnecessary antibiotics

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References

Bartlett JG, Gerding DN: Clinical recognition and diagnosis of Clostridium difficile infection. Clin Infect Dis 2008;46(Suppl 1):S12.
Dallal RM et al: Fulminant Clostridium difficile: an underappreciated and increasing cause of death and complications. Ann Surg 2002;235:363.  [PubMed: 11882758]
Hall JF, Berger D: Outcome of colectomy for Clostridium difficile colitis: a plea for early surgical management. Am J Surg 2008;196:384.  [PubMed: 18519126]
Nelson R: Antibiotic treatment for Clostridium difficile–associated diarrhea in adults. Cochrane Database Syst Rev 2007;3:CD004610.

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