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

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