Clostridium Difficile Infection

Clostridium difficile is a spore-forming, toxin-producing gram-positive anaerobe. Colonizes the human intestinal tract after gut flora has been disrupted. Usually follows antibiotic therapy. Produces two toxins – A and B.

Implicated antibiotics;

• Fluoroquinolones
• Clindamycin
• Penicillins
• Cephalosporins

Risk factors for Clostridium difficile

• Age>65
• Immunosuppression
• Comorbidities

Clinical Presentation

1. Non-severe disease

• Watery diarrhea, lower abdominal pain, fever, nausea, anorexia
• Abdominal tenderness on examination
• Symptoms start in the first week of antibiotics till any time up to 6 weeks after treatment

2. Severe disease

• Diarrhea, diffuse abdominal pain, distention, fever, hypovolemia
• Laboratory markers; acidosis, leukocytosis, hypoalbuminemia, raised creatinine

3. Fulminant colitis; hypotension or shock, ileitis, megacolon.

Investigations

1. Stool culture – identifies the organism
2. Enzyme immunoassay – for toxins A and B
3. Cell culture cytotoxic assay
4. Complete blood count – Leucocytosis
5. Urea, creatinine, and electrolytes- raised creatinine.
6. LFT – low albumin
7. Endoscopy- mucosa visualization
8. CT scan or erect abdominal Xray – perforation, toxic megacolon
9. Screening; PCR and enzyme immunoassay for glutamate dehydrogenase

Management

• Stop precipitating antibiotics and isolate the patient
• Supportive – IV fluids and bowel rest
• Antimicrobials;
• Metronidazole 500mg PO tds for 10 days
• Vancomycin 125mg PO Qid for 7 to 10 days
• Alternative; fidaxomicin
• IV immunoglobulin or glucocorticoids for severe or refractory disease
• Faecal transplant
• Surgical – for severe disease

Differential diagnosis

• Acute abdomen
• Infectious diarrhoea
• Irritable bowel syndrome
• Inflammatory bowel disease
• Celiac disease