Clostridium difficile

Background

• Most common cause of infectious diarrhea in hospitalized pts
• Use contact isolation if suspect
• Risk factors for pseudomembranous colitis:
  • Recent abx use (any)
  • GI surgery
  • Severe underlying medical illness
  • Chemo
  • Elderly

Diagnosis

History

• Diarrhea that develops during abx use or w/in 2wk of discontinuation
• Recent discharge from hospital
• Profuse watery diarrhea

Exam

• Abdominal pain
• Fever
• Leukocytosis
• +Fecal leukocytes (distinguishes from benign forms of abx-induced diarrhea)

Labs

• C. diff toxin assay
  • Sn 63-94%, Sp 75-100%
• Culture
  • Positve culture only means C. diff present, not necessarily that it is causing disease

Treatment

• Mild
  • Either d/c offending abx (if possible) or give metronidazole 500mg PO q6hr x10-14d
• Moderate
  • Metronidazole 500mg PO or IV q6hr x10-14d
• Severe
  • Criteria
    • Age >60yr
    • Temp >38.4 (101)
    • Serum albumin <2.5
    • WBC >15K
    • Pt requires ICU admission
    • Pseudomembranous colitis on endoscopy
  • Tx
    • Vancomycin 125-250mg PO q6hr x10d
    • Add metronidazole 500mg IV q6hr if ileus or pt cannot tolerate PO
• Emergency colectomy should be considered if:
  • WBC >20K
  • Lactate >5
  • Age >75
  • Immunosuppression
  • Toxic megacolon
  • Colonic perforation
  • Multi-organ system failure

Disposition

• Admit:
  • Severe diarrhea
  • Oupt abx failure
  • Systemic response (fever, leukocytosis, severe abdominal pain)

Source

Tintinalli