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Clostridium Difficile Infection

Clostridium difficile is a gram-positive anaerobic bacterium. It most often results in antibiotic-associated diarrhea. Symptoms may range from asymptomatic carrier states to severe pseudomembranous colitis and are caused by the exotoxins produced by the organism. Toxin A is an enterotoxin and toxin B is a cytotoxin.

Causes

C. difficile can cause diarrhoea, ranging from a mild disturbance to a very severe illness with ulceration and bleeding from the colon (colitis) and, at worst, perforation of the intestine leading to peritonitis. It can be fatal.

Generally, it is only able to do this when the normal, healthy intestinal bacteria have been killed off by antibiotics. When not held back by the normal bacteria, it multiplies in the intestine and produces two toxins (A and B) that damage the cells lining the intestine. The result is diarrhoea.

Symptoms and Signs

Symptoms include:

  • watery diarrhea (at least three bowel movements per day for two or more days)
  • fever
  • loss of appetite
  • nausea
  • abdominal pain/tenderness

Diagnostic tests

Diagnosis is by identification of the toxin through one of the following acceptable methods:

  • cell cytotoxin test - tests for both toxin A and B; this takes 2 days to perform. It's highly sensitive and specific for C. difficile.
  • enzyme immunoassays - slightly less sensitive than the cell cytotoxin test but has a turnaround time of only a few hours. Specificity is excellent.
  • stool culture - the most sensitive test; has a turnaround time of 2 days to obtain results. Non-toxin­producing strains of C. difficile can be easily identified and must be further tested for presence of the toxin.
  • endoscopy (flexible sigmoidoscopy) - may be used in a patient who presents with an acute abdomen but no diarrhea, making it difficult to obtain a stool specimen. If pseudo membranes are visualized, treatment for C. difficile is usually initiated.

Treatment

After withdrawing the causative antibiotic (if possible), symptoms resolve in patients who are mildly symptomatic. This is usually me only treatment needed. In more severe cases, metronidazole 250 mg should be given orally, four times a day or 500 mg orally three times a day, or vancomycin 125 mg orally, four times a day for 10 days; metronidazole is the preferred treatment. Retesting for C. difficile is unnecessary if symptoms resolve.

Ten to 20 percent of patients may have a recurrence with the same organism within 14 to 30 days of treatment. Beyond 30 days, a recurrence may be a relapse or reinfection of C. difficile. If the previous treatment was metronidazole, low-dose vancomycin 125 mg four times daily for 21 days may be an effective choice. An alternative treatment combines vancomycin 125 mg four times daily and rifampin 600 mg orally twice a day for 10 days.

There is no evidence to support the effectiveness of eating yogurt or taking lactobacillus. Other experimental treatments involve the administration of yeast Saccharomyces boulardii with metronidazole or vancomycin and biologic vaccines to restore the normal GI flora.

Prevention
  • Prudent antibiotic prescribing to reduce the use of broad spectrum antibiotics
  • Isolation of patients with C. difficile diarrhoea and good infection control nursing - handwashing - wearing gloves and aprons, especially when dealing with bed pans etc
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