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clostridium_difficile

Clostridium difficile

introduction

  • Clostridium difficile is a Gram positive, anaerobic, heat-resistant spore forming bacillus which is a common cause of antibiotic-related nosocomial colitis, and in its severe form, pseudomembranous colitis.
  • it is present in 2-3% of normal adults and in 70% of healthy infants
  • ~20% of patients who are hospitalised acquire this organism, and ~1/3rd of these develop diarrhoea.
  • it should be suspected as the cause of diarrhoea in any patient who has had antibiotics in the previous 2 months, or if diarrhoea develops after 72 hours of hospitalisation.
  • most patients recover without specific treatment, but mortality rates of up to 25% occur in the frail elderly.
  • pathogenic strains produce two toxins - Toxin A is an enterotoxin, while Toxin B is a cytotoxin.
  • a hypervirulent strain (NAP/027) has spread through Nth America and Europe since 2003, and in 2010 has reached Australia

risk factors

prevention

  • avoidance of unnecessary antibiotics or hospitalisation
  • strict adherence to infection control such as hand washing
  • isolate patients who are incontinent with diarrhoea
  • environmental cleaning with sodium hypochlorite solution
  • avoid using diclofenac non-steroidal anti-inflammatory agent as this seems to increase risk by 35% 1)
  • proton pump inhibitors (PPIs) appear to almost double the risk (1.7x) 2)

diagnosis

  • rapid stool testing kits are available
  • the EIA tests are only 80% sensitive, thus a negative result does not exclude serious disease
    • detect C. difficile glutamate dehydrogenase (GDH) or toxins A or B
  • the much more expensive PCR test is more sensitive

indicators of possible severe disease

  • age > 60 years
  • temp > 38.3 deg C
  • serum albumin < 25 g/L
  • peripheral WCC > 15,000 cells/microL
  • deteriorating renal function
  • elevated serum lactate
  • endoscopic evidence of pseudomembranous colitis or ICU Rx
  • subtotal colectomy performed
  • toxic megacolon

antibiotic Rx

  • cease aetiologic antibiotics if possible
  • oral or NGT metronidazole tds for 10 days, if not tolerated, can be given iv
  • it would appear the most effective Rx is a faecal transplant - faeces from a healthy donor is placed in the colon. This appears to resolve even chronic cases within 24 hours! - see news story
  • severe cases may need oral or NGT (NOT iv as not effective) vancomycin 6hrly for 10 days +/- iv metronidazole tds 10 days
  • see therapeutic guidelines for more detailed Mx.
clostridium_difficile.txt · Last modified: 2018/08/11 14:11 (external edit)