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Updated: Oct 6 2022

Clostridioides difficile

  • 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 and alcohol-resistant spores
        • part of normal GI flora
    • Epidemiology
      • incidence
        • common
      • risk factors
        • recent antibiotics use
          • 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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