Clostridium difficile infection
Clostridium difficile is a gram-positive anaerobic bacterium usually linked to antibiotic-associated diarrhea. Symptoms may range from asymptomatic carrier states to severe pseudomembranous colitis and are caused by exotoxins produced by the organism: toxin A (an enterotoxin) and toxin B (a cytotoxin).
Causes
Although C. difficile infection can be caused by almost any antibiotic that disrupts the intestinal flora, it’s typically associated with clindamycin use. Patients at high risk for this disorder include those taking many kinds of antibiotics or antineoplastics that have antibiotic activity; candidates for abdominal surgery; immunocompromised individuals; pediatric patients (infections are common in day-care centers); and those in nursing homes.
Other factors that alter normal intestinal flora include enemas and intestinal stimulants. C. difficile may be transmitted directly from patient to patient via contaminated hands of facility personnel (most common) or indirectly through contaminated equipment (such as bedpans, urinals, call bells, rectal thermometers, and nasogastric tubes) and surfaces (such as bed rails, floors, and toilet seats).
Clinical tip Because spores of C. difficile are resistant to most commonly used facility 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.
Signs and symptoms
Risk of C. 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 he may experience any of the following signs or symptoms: soft, unformed stool or watery diarrhea (more than three evacuations in 24 hours) that may be foul-smelling or grossly bloody; abdominal pain, cramping, or tenderness; and fever. White blood cell count may be elevated to 20,000/µl. In severe cases, toxic megacolon, colonic perforation, and peritonitis may develop. Complications include electrolyte abnormalities, hypovolemic shock, anasarca (caused by hypoalbuminemia), sepsis, and hemorrhage. In rare cases, death may result.
Diagnosis
C. difficile infection is confirmed by identification of toxins, using one of the following methods:
❑ cell cytotoxin test — highly sensitive and specific for toxins A and B of C. difficile; results available in 2 days
❑ enzyme immunoassays — slightly less sensitive than the cell cytotoxin test, but results are obtained in a few hours; specificity is excellent
❑ stool culture — most sensitive, with 2-day turnaround. Non–toxin-producing strains of C. difficile can be easily identified using three separate stool samples to test for the presence of the toxin
❑ endoscopy (flexible sigmoidoscopy) — may be used in a patient with an acute abdomen but no diarrhea, making it difficult to obtain a stool sample. If pseudomembranes are seen, treatment for C. difficile is usually initiated.
Treatment
Withdrawing the causative antibiotic resolves symptoms in patients who are mildly symptomatic. This is usually the only treatment required.
For more severe cases, metronidazole orally for 10 to 14 days or vancomycin 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 may be effective.
UNDER STUDY: Lactobacillus has been used in some uncontrolled studies.
Other experimental treatments include giving the yeast Saccharomyces boulardii and giving biological vaccines to restore normal intestinal flora. I.V. immunoglobulin has been successful in children and adults with relapsing infections, although it’s still being studied.
Special considerations
❑ If the patient has or is suspected of having C. difficile diarrhea and is unable to practice good hygiene, he should be placed in a single room or with other patients with similar health status.
❑ Standard precautions for contact with blood and body fluids should be used for all direct patient contact and contact with the patient’s immediate environment. Use good hand-washing technique with antiseptic soap after direct contact with the patient or the immediate environment.
❑ If the patient is asymptomatic without diarrhea or fecal incontinence for 72 hours and is able to practice good hygiene, he may be transferred to a single room.
❑ Reusable equipment must be disinfected before it’s used on another patient.
❑ Preventive strategies include careful selection of antibiotic therapy, use of a single antibiotic when possible, avoidance of antibiotics when they aren’t absolutely necessary, and limited duration of the antibiotic treatment regimen.
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
Other Book Chapters Related to Infection
Read excerpts from these other book chapters related to Infection:
Copyright Details: Handbook of Diseases, Copyright © 2008 Williams & Wilkins.
More About Causes of Infection
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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