Updated: 9/30/2020

Clostridioides difficile

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Snapshot
  • An 89-year-old man with a past medical history of gastritis presents to the hospital for dehydration and watery diarrhea. He started having diarrhea and some weakness about 2 days ago and had not been able to keep up with his fluid intake. He has been taking omeprazole for over 30 years and was recently treated with clindamycin for a soft tissue infection. On laboratory evaluation, he has a marked leukocytosis. He is started on oral vancomycin.  
Introduction
  • Classification
    • Clostridioides difficile 
      • anaerobic, gram + rod
      • produces 2 toxins that bind to intestinal mucosal cells
      • forms heat-resistant spores
      • part of normal GI flora 
  • Epidemiology
    • incidence
      • common
    • risk factors
      • recent antibiotics use
        • clindamycin
        • ampicillin
        • cephalosporins
        • fluoroquinolones
      • proton-pump inhibitors
      • recent hospitalization
      • advanced age
  • Pathogenesis
    • causes a pseudomembranous colitis and diarrhea  
      • characterized by yellow-white plaques in intestinal mucosa
      • pseudomembranous plaques are made from fibrin
    • toxin A is an enterotoxin that binds to the intestinal brush border
    • toxin B is a cytotoxin and depolymerizes actin, disrupting the cytoskeleton
  • Prognosis
    • relapse occurs in ~20% of patients
Presentation
  • Symptoms 
    • crampy abdominal pain
    • anorexia
    • malaise
    • diarrhea
      • typically watery diarrhea
      • occasionally may be bloody but without frank blood
  • Physical exam
    • fever
    • dehydration
    • abdominal tenderness to palpation
    • rebound tenderness in severe cases
Imaging
  • Abdominal radiography
    • indications
      • if toxic megacolon is suspected
      • for quick diagnosis and assess for early intervention
    • findings
      • dilated colon
  • Abdominal computed tomography (CT)
    • indication
      • suspicion for pseudomembranous colitis
    • findings
      • marked thickening of the colonic wall (accordion sign)
      • irregularity of bowel wall
      • pericolonic stranding
Studies
  • Labs
    • ↑ white blood cells
    • ↓ hypoalbuminemia
    • ↑ lactate
    • diagnostic tests of the stool
      • polymerase chain reaction for the organism
      • detection of antigen
      • + fecal leukocytes
  • Making the diagnosis
    • based on clinical presentation and stool studies
Differential
  • Ulcerative colitis
    • distinguishing factors
      • typically presents with bloody diarrhea
      • can also present with dermatologic manifestations such as erythema nodosum
  • Crohn disease
    • distinguishing factors
      • can be bloody or nonbloody
      • can present with fistulas
      • can also present with dermatologic manifestations such as erythema nodosum
Treatment
  • Management approach
    • 10-day course of antibiotics
  • Medical
    • oral vancomycin
      • indications
        • resistant to metronidazole
        • severe cases
    • fidaxomicin
      • indication
        • recurrent cases
    • oral metronidazole
      • indications
        • used as an alternative if vancomycin or fidaxomicin are not available
        • used in addition to vancomycin if patients are refractory to monotherapy
        • contraindicated in the elderly
    • fecal microbiota transplant
      • indication
        • recurrent cases
Complications
  • Colonic perforation
    • occurs in small percentage of patients
  • Toxic megacolon
    • occurs in small percentage of patients
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Questions (8)
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(M1.MC.15.29) A 68-year-old alcoholic male who is hospitalized for treatment of a pulmonary abscess with clindamycin develops recurrent foul, watery diarrhea on day 6 of his hospitalization. His condition has otherwise improved, with only a low grade fever and mild abdominal pain. A stool toxin study is sent which successfully diagnoses the cause of his diarrhea. Which of the following histologic images best corresponds to this patient's pathology? Tested Concept

QID: 103519
FIGURES:
1

Figure A

7%

(16/236)

2

Figure B

6%

(14/236)

3

Figure C

25%

(58/236)

4

Figure D

53%

(124/236)

5

Figure E

8%

(19/236)

M 1 B

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(M1.MC.12.91) An 87-year-old male nursing home resident is currently undergoing antibiotic therapy for the treatment of a decubitus ulcer. One week into the treatment course, he experiences several episodes of watery diarrhea. Subsequent sigmoidoscopy demonstrates the presence of diffuse yellow plaques on the mucosa of the sigmoid colon. Which of the following is the best choice of treatment for this patient? Tested Concept

QID: 101550
1

Oral morphine

2%

(1/48)

2

Intravenous gentamicin

4%

(2/48)

3

Oral metronidazole

71%

(34/48)

4

Oral trimethoprim/sulfamethoxazole

2%

(1/48)

5

Intravenous vancomycin

19%

(9/48)

M 3 D

Select Answer to see Preferred Response

(M1.MC.12.7) A 58-year-old man is hospitalized and treated with clindamycin for a pulmonary abscess. During his hospital stay he develops abdominal pain and bloody diarrhea, and has a WBC of 14,000; serum creatinine is 0.9 mg/dL. On teaching rounds, you learn that the responsible pathogen produces a multi-unit toxin that binds to the colonic mucosa, causing actin depolymerization that results in cell death and mucosal necrosis. What is the preferred treatment for this condition? Tested Concept

QID: 101466
1

Continue Clindamycin

4%

(14/390)

2

Metronidazole

80%

(312/390)

3

Penicillin G

5%

(18/390)

4

Tetracycline

5%

(19/390)

5

Erythromycin

6%

(23/390)

M 1 D

Select Answer to see Preferred Response

Evidence (5)
Topic COMMENTS (6)
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