CASES/YEAR
500,000 (US); 10,000,000 (Global)
OTHER NAMES
Clostridioides difficile-induced diarrhea; Antibiotic-associated colitis; Pseudomembranous colitis; Clostridium difficile infection (CDI);
INCUBATION
From the time of the initiation of antibiotics to several weeks after the discontinuation of antibiotics; [PPID, p. 2940]
INITIAL SYMPTOMS
C. diff causes about 20% of antibiotic-associated diarrhea; [ABX Guide] Diarrhea almost never grossly bloody & as many as 20 stools/day; Diagnosis frequently overlooked in cases with adynamic ileus; [Harrison ID, p. 295]
PRECAUTIONS
Contact for duration of illness; "Discontinue antibiotics if appropriate. Do not share electronic thermometers. Ensure consistent environmental cleaning and disinfection. Hypochlorite solutions may be required for cleaning if transmission continues. Handwashing with soap and water preferred because of the absence of sporicidal activity of alcohol in waterless antiseptic handrubs." [CDC 2007 Guideline for Isolation Precautions]. "Patients with CDI should be hospitalized in a private room with a dedicated toilet." [ABX Guide]
COMMENTS
FINDINGS:
Clostridium difficile-associated disease should be suspected in patients with diarrhea receiving antibiotics or who have discontinued antibiotics within the last several weeks. About 25% of infections are expected to resolve without specific treatment. Clinical findings include fever, leukocytosis, abdominal cramping, and tenesmus. Complications are toxic megacolon, intestinal perforation, and shock. About 25% of patients need retreatment for recurrent disease. [PPID, p. 2936-42] High-risk antibiotics are clindamycin, 3rd or 4th generation cephalosporins, carbapenems (imipenem) and fluoroquinolones. [ABX Guide] C. difficile infection (CDI) is caused by a spore-forming anaerobic bacteria and affects mainly hospitalized patients treated with antibiotics. Hospitalized patients after one week have colonization rates of >20%, while community residents have rates of 1-3%. Spores persist on environmental surfaces for months. CDI has become a severe problem in hospitals in the United States, Canada, and Europe. An epidemic strain can produce toxin (A and B) 16-23 times greater than that produced by control strains. [Harrison ID, p. 294-5] Septic shock is a complication. Intestinal obstruction is one of the indications for surgery. [Guerrant, p. 165] Nausea and vomiting are rare. {Merck Manual, p. 1467] CDI cases are either hospital acquired (85%) or community acquired (15%). Suspect CDI when diarrhea in adult patient >48 hours after admission because other enteric pathogens are extremely rare in this setting (with the exception of norovirus). [Cecil, p. 1891]
DIAGNOSTIC TESTS:
"Diagnosis: enzyme immunoassays for the detection of TcdA and/or TcdB, membrane immunoassay to detect the antigen glutamate dehydrogenase and toxin, and polymerase chain reaction." [PPID, p. 2960] C. difficile toxins are present in about 15-25% of antibiotic-associated diarrhea cases and about 90-100% of pseudomembranous colitis cases. Pseudomembranous colitis can usually be detected by sigmoidoscopy, but colonoscopy is necessary in as many as 1/3 of patients who have lesions confined to the right colon. Abnormalities on CT of the abdomen are seen in about 1/2 of patients with positive toxin assays. [ID, p. 670-7]
DIAGNOSTIC
Detect Toxin A or B (lack sensitivity) in patient with diarrhea or identify pseudomembranes; PCR assays were approved recently; they are rapid, sensitive, and specific. [Harrison ID, p. 296]
SIGNS & SYMPTOMS
-
>fever
-
G abdominal pain
-
G blood in stool
-
G diarrhea
-
G fecal leukocytes
-
G nausea, vomiting
-
H leukocytosis
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*acute renal failure
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*arthritis
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*bowel obstruction
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*sepsis
-
*shock
SOURCE
Person-to-Person, Human Fecal-Oral
TREATMENT
"When a negative test result does not confirm the diagnosis in a patient whose clinical symptoms are highly suggestive of CDI, empirical treatment for CDI should be given rather than repeating the test." [Cecil, p. 1891]
REFERENCES FOR CASES/YEAR
1. (US) Estimated 3 million case per year in the US; [Gorbach, p. 76] Estimated 500,000 cases per year and 30,000 deaths per year; [Cecil, p. 1890]
2. (Global) Scant data from developing countries; [Guerrant, p. 162] Estimate: global cases/yr = 20 X US cases/yr;