Clostridium difficile infection is ...

Clostridium difficile infection is responsible for approximately 3 million cases of diarrhea and colitis annually in the United States. The mortality rate is 1 to 25 percent Early diagnosis and willing aggressive treatment are critical in managing C difficile-associated diarrhea. Major predisposing factors for symptomatic C difficile colitis include antibiotic therapy; advanced age; multiple, rigid underlying diseases; and a faulty immune answer to C. difficile toxins. The greatest in number common confirmatory study is an enzyme immunoassay for C difficile toxins A and B The ordeal is easy to perform, and flows are available in two to four hours. Specificity of the assay is high (93 to 100 percent) unless sensitivity ranges from 63 to 99 percent In relentless cases, flexible sigmoidoscopy can provide an immediate diagnosis. Treatment of C difficile-associated diarrhea includes discontinuation of the precipitating antibiotic (if possible) and the administration of metronidazole or vancomycin. Preventive measures include the judicious use of antibiotics, thorough hand washing between patient contacts, use of precautions when handling an infected patient or items in the patient's immediate environment, accurate disinfection of objects, education of staff members, and isolation of the patient.

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Clostridium and nearly all cases difficile is a gram-positive, spore-forming slender stem that is responsible for 15 to 20 percent of antibiotic-related cases of diarrhea of pseudomembranous colitis. (1) The species was named "difficile" because initially it was hard to agriculture (2) Early studies showed that C difficile could be isolated from the gastrointestinal tracts of greatest in number neonates; thus, it was believed to be a commensal organism. In the late 1970 however, C difficile was ground to be the primary cause of pseudomembranous colitis. (3) Because of the resort to frequently use of broad-spectrum antibiotics, the incidence of C difficile diarrhea has risen dramatically in fresh decades. (4,5)

C difficile-associated diarrhea repeatedly is perceived to be an occasional and easily treated side consequence of antibiotic therapy. Research has shown however, that C difficile infection accounts for considerable increases in the detail of hospital stays and more than $11 billion in health care prices each year in the United States. (5) The condition is a customary cause of significant morbidity and calm death in elderly or debilitated patients.

Family physicians should stres preventive measures for C difficile-associated diarrhea (especially the judicious use of antibiotics) and should maintain a high index of suspicion for C difficile infection in their patients.

Illustrative Case

An 87-year-old white woman was readmitted to the hospital because of intermittent pneumonia. Ten days earlier, she had been treated for right lower lobe pneumonia at another institution. She was discharged forward moxifloxacin (Avelox) and doxycycline (Vibramycin). She turn backed home, where she was recovering, yet then she became weak, short of breath, and constipated.

in succession readmission, chest radiography revealed right lower lobe pneumonia. The patient's white vital fluid cell (WBC) count was 16300 by [mm.sup.3] (16.3 x [10.sup.9] by means of L), compared with 7,500 by means of [mm.sup.3] (7.5 x [10.sup.9] by L) during her previous hospitalization.

At the time of readmission, the patient was afebrile, and her vital signs were stable. Moxifloxacin and doxycycline were continued. Overnight, however, the patient became febrile, and her WBC cast rose to 36,000 per [mmsup3] (36 x [10sup9] by means of L). She also passed several set free stools. In light of the patient's fresh history of antibiotic use, the unexpected leukocytosis, her age and frail condition, and her new hospital admission, C. difficile- associated diarrhea was considered, and a stool sample was obtained for analysis.

Empiric treatment with oral metronidazole (Flagyl) and famotidine (Pepcid) was initiated. Shortly thereafter, the patient unraveled marked hypotension. Fluid boluses produc no improvement, and a dopamine (Intropin) drip was started. Moxifloxacin and doxycy-cline were discontinued, and treatment with oral vancomycin (Vancocin), intravenous metronidazole, and intravenous ceftizoxime (Cefizox); (anti-C. difficile-associated diarrhea therapy) was started.

Sigmoidoscopy revealed diffuse pseudo-membranes from first to last the patient's distal colon, confirming C difficile infection (Figure 1) An abdominal comput tomographic (CT) scan was consistent with this diagnosis. Ceftizoxime was discontinued, and total parenteral nutrition was initiated.

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through the whole extent of the next eight days, the patient's condition continued to decline as she became more acidotic, her urine output diminished, her mental status fluctuated, and her abdomen became grossly distended and tympanic. Subtotal colectomy and ileostomy were considered, further were refused by the patient and her husband.

After more than a week of strait-laced illness, the patient began to improve. Eventually, she was transferred to a skilled nursing facility for rehabilitation.