Clostridium difficile Colitis

Abstract

Clostridium difficile colitis should be suspected in patients with watery foul-smelling diarrhea who have recently been hospitalized or exposed to antibiotics. Stool should be evaluated for C. difficile toxin to establish the diagnosis. Abdominal exam, white blood cells (WBC), and renal function should be used to determine the severity of infection. Patients with fulminant colitis, such as signs of systemic toxicity, should have a computed tomography (CT) scan to determine the extent of inflammation and dilation of the colon. If the colon is perforated, a total abdominal colectomy with end ileostomy should be performed. Management of mild disease is with metronidazole and per oral (PO) vancomycin for severe disease. Severe-complicated disease is treated with a combination of vancomycin PO and metronidazole IV and vancomycin enemas if ileus is suspected. Fecal transplant should be considered in patients with relapsing or refractory disease.

Algorithmic Approach

• A. In the setting of new onset diarrhea , history and physical examination are the first step with specific inquiry about risk factors for C. difficile colitis. Usually, the diarrhea is watery. The strongest risk factor is recent antibiotic use, and patients who are immunosuppressed or diagnosed with inflammatory bowel disease are at higher risk [1]. Physical examination should evaluate for abdominal distention and peritoneal signs.

• B. A diarrhea l specimen should be evaluated for C. difficile toxin [2].

• C. With a positive assay, the severity of colitis is determined next. Vital signs and laboratory studies including complete blood count (CBC), electrolytes, renal function, and albumin should be obtained.

• D. Patients should be evaluated for fulminant C. difficile colitis, which includes systemic toxicity, hypotension, oliguria, tachycardia, or perforation [3]. A plain abdominal X-ray may be obtained to evaluate for toxic megacolon. With a concerning physical exam, a CT scan can assist in determining the extent of colonic inflammation and can further characterize signs of perforation or impending perforation with pneumatosis.

• E. If fulminant disease or perforation is identified, total abdominal colectomy with end ileostomy and a stapled rectal stump is the safest surgical option [4].

• F. Without peritoneal signs or perforation, antibiotic therapy in addition to supportive care is indicated. The antibiotic regimen chosen is based upon disease severity as listed below [5]:

  • (a) Mild disease (WBC <15,000 and creatinine (Cr) less than 1.5 times baseline) is treated with oral or IV antibiotic therapy with metronidazole 500 mg tid for 10–14 days.

  • (b) Severe disease (WBC >15,000 and/or Cr >1.5 times baseline Cr) is treated with 125 mg vancomycin PO qid for 10–14 days.

  • (c) Severe-complicated disease is characterized by additional complicating factors, including ileus, shock requiring vasopressors, and megacolon, or worsening symptoms or lack of improvement after 5 days of antibiotic treatment. CT scans of the abdomen/pelvis should be obtained. Treatment: IV metronidazole 500 mg tid, PO vancomycin 125 mg qid, and if ileus: add vancomycin enema 500 mg qid.

• G. Continue to monitor patient for signs of C. difficile colitis. Patients who clinically worsen or do not respond to medical therapy should be evaluated for surgical intervention. Patients with refractory or recurrent disease should be considered for fecal microbiota transplant prior to surgical intervention [6].

Algorithm 63.1