Gastroenterology & Hepatology
Question 160 of 180
A 78 year old woman, recovering in hospital after a fractured neck of femur, develops profuse diarrhoea. She has been on broad spectrum antibiotics for a postoperative urinary tract infection. Which of the following pathogens is the most likely cause of her diarrhoea?
Answer:
Clostridium difficile is the most likely cause given the hospital stay and the prolonged course of a broad spectrum antibiotic.Clostridium Difficile Infection
Gastroenterology & Hepatology
Last Updated: 8th September 2021
Around 20–30% of cases of antibiotic-associated diarrhoea are due to Clostridium difficile.
Risk factors
Risk factors for Clostridium difficile infection include:
- Increased age (> 65 years)
- Antibiotic treatment
- Antibiotics that have been frequently associated with C. difficile infection include clindamycin, cephalosporins (especially third and fourth generation), fluoroquinolones, and broad-spectrum penicillins.
- The risk of C. difficile is also increased with longer duration of antibiotic treatment, multiple antibiotics prescribed concurrently, or multiple courses of antibiotics.
- Underlying morbidity such as abdominal surgery, chronic renal disease, inflammatory bowel disease, immunosuppression (such as solid organ or haematopoietic stem cell transplant recipients, people with HIV infection, people undergoing cancer chemotherapy)
- Current use of a proton pump inhibitor or other acid-suppressive drugs (such as H2-receptor antagonists)
- Prolonged hospitalisation or residence in a nursing home
- History of C. difficile infection
- Recurrence risk is 20% after the first episode and 60% after multiple previous recurrences
- Exposure to other cases — C. difficile infection can occur in outbreaks
- Inflammatory bowel disease
Severity assessment
Severity of Clostridium difficile infection can be defined as
- Mild: not associated with an increased white cell count (WCC). It is typically associated with less than three episodes of loose stools (defined as loose enough to take the shape of the container used to sample it) per day.
- Moderate: associated with an increased WCC (but less than 15 x 109/L) and typically associated with 3–5 loose stools per day.
- Severe: associated with a WCC greater than 15 x 109/L, or an acutely increased serum creatinine concentration (that is, greater than 50% increase above baseline), or a temperature higher than 38.5°C, or evidence of severe colitis (abdominal or radiological signs). The number of stools may be a less reliable indicator of severity.
- Life-threatening: signs and symptoms include hypotension, partial or complete ileus, toxic megacolon, or computerised tomography (CT) evidence of severe disease.
Investigations
For adults with suspected Clostridium difficile infection:
- Send a stool sample to test for C. difficile infection if the person is symptomatic with liquid/loose stools (with a consistency that takes the shape of the container — ideally 1/4 filled) that is not clearly attributable to another condition or therapy, and C. difficile infection is suspected, for example if the person:
- Has been in contact with a person with C. difficile infection.
- Has recently had a course of antibiotics, proton-pump inhibitor treatment, or been in hospital.
- Do not wait to initiate sampling or testing as any delay may increase the severity of the disease and the risk of C. difficile transmission.
- Ensure the following details are stated on the request form:
- Clinical features (for example nature and duration of symptoms).
- Recent antibiotic or proton pump inhibitor, or hospital admission.
- Contact with other affected individuals or outbreak.
- Underlying illness.
- State if the test was requested by the Health Protection Team, a Consultant in Communicable Disease Control, or a Consultant in Health Protection.
- Check the full blood count and serum creatinine in order to help assess the severity of C. difficile.
- Consider re-testing if the first test is negative and there is a strong clinical suspicion of C. difficile infection — seek advice from a consultant medical microbiologist or infection control doctor.
- Do not retest people with a positive C. difficile infection if they are still symptomatic within the same episode. Only retest to confirm recurrent C. difficile infection if the symptoms resolve and then recur.
- Do not test to confirm cure.
Management
- For people with suspected or confirmed C. difficile infection:
- Assess:
- whether it is a first or further episode (relapse or recurrence) of C. difficile infection
- the severity of C. difficile infection individual factors such as age, frailty or comorbidities that may affect the risk of complications or recurrence.
- Review existing antibiotic treatment and stop it unless essential. If an antibiotic is still essential, consider changing to one with a lower risk of causing C. difficile infection.
- Review the need to continue any treatment with:
- proton pump inhibitors
- other medicines with gastrointestinal activity or adverse effects, such as laxatives
- medicines that may cause problems if people are dehydrated, such as non-steroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, angiotensin‑2 receptor antagonists and diuretics.
- Offer an antibiotic to treat suspected or confirmed C. difficile infection:
- First-line antibiotic for a first episode of mild, moderate or severe C. difficile infection: Vancomycin 125 mg orally four times a day for 10 days
- Second-line antibiotic for a first episode of mild, moderate or severe C. difficile infection if vancomycin is ineffective: Fidaxomicin 200 mg orally twice a day for 10 days
- Antibiotics for life-threatening C. difficile infection: Seek urgent specialist advice, which may include surgery. Antibiotics that specialists may initially offer are: Vancomycin 500 mg orally four times a day for 10 days with metronidazole 500 mg intravenously three times a day for 10 days
- Manage fluid loss and symptoms as for acute gastroenteritis. Do not offer antimotility medicines such as loperamide.
- Implement hygiene and isolation measures to minimise the spread of C. difficile. Note that alcohol-based hand rubs are not effective in removing C.difficile spores.
- Reassess people with suspected or confirmed C. difficile infection if symptoms or signs do not improve as expected, or worsen rapidly or significantly at any time. Daily review may be needed, for example, if the person is in hospital.
- Assess:
Complications
- Pseudomembranous colitis
- Toxic megacolon
- Colonic perforation
- Paralytic ileus
- Sepsis
- Death
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
