Disease Information for C Difficile/lPseudomembranous colitis (Synonyms)

C Difficile Colitis, CLOSTRIDIUM DIFFICILE COLITIS, Clostridium difficile colitis (disorder), COLITIS CLOSTRIDIA DIFFICILE, ENTEROCOLITIS PSEUDOMEMBRANOUS ACUTE

Clostridium difficile infection is responsible for approximately 3 million cases of diarrhea and colitis annually in the United States; The mortality rate is 1 to 2; 5 percent; Early diagnosis and prompt aggressive treatment are critical in managing C; difficile-associated diarrhea; Major predisposing factors for symptomatic C; difficile colitis include antibiotic therapy; advanced age; multiple, severe underlying diseases; and a faulty immune response to C; difficile toxins; The most common confirmatory study is an enzyme immunoassay for C; difficile toxins A and B; The test is easy to perform, and results are available in two to four hours; Specificity of the assay is high (93 to 100 percent), but sensitivity ranges from 63 to 99 percent; In severe cases, flexible sigmoidoscopy can provide an immediate diagnosis; Treatment of C; difficile-associated diarrhea includes discontinuation of the precipitating antibiotic (if possible) and the administration of metronidazole or vancomycin; Preventive measures include the judicious use of antibiotics, thorough hand washing between patient contacts, use of precautions when handling an infected patient or items in the patient"s immediate environment, proper disinfection of objects, education of staff members, and isolation of the patient; (Am Fam Physician 2005;71:921-28; Copyright© 2005 American Academy of Family Physicians; )<br>

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Clostridium difficile is a gram-positive, spore-forming rod that is responsible for 15 to 20 percent of antibiotic-related cases of diarrhea and nearly all cases of pseudomembranous colitis; 1 The species was named "difficile" because initially it was hard to culture; 2 Early studies showed that C; difficile could be isolated from the gastrointestinal tracts of most neonates; thus, it was believed to be a commensal organism; In the late 1970s, however, C; difficile was found to be the primary cause of pseudomembranous colitis; 3 Because of the frequent use of broad-spectrum antibiotics, the incidence of C; difficile diarrhea has risen dramatically in recent decades; 4,5<br>

The case mortality rate is approximately 1 to 2; 5 percent; Until recently, C; difficile infection was thought to result from an overgrowth of commensal organisms in the colon; however, studies have shown that fewer than 3 percent of adults carry this pathogen; Pseudomembranous colitis on endoscopy: Irregular yellow plaques of necrotic debris (black arrow) with intervening edematous bowel mucosa ; Acquisition of C; difficile occurs primarily in the hospital setting, where the organism has been cultured from bed rails, floors, windowsills, and toilets, as well as the hands of hospital workers who provide care for patients with C; difficile infection (Table 1); 4,6 The organism can persist in hospital rooms for up to 40 days after infected patients have been discharged; Risk Factors for Clostridium difficile-Associated Diarrhea: Admission to intensive care unit, Advanced age, Antibiotic therapy, Immunosuppressive therapy, Multiple and severe underlying diseases, Placement of a nasogastric tube, Prolonged hospital stay, Recent surgical procedure, Residing in a nursing home, Sharing a hospital room with a C; difficile-infected patient, Use of antacids; <br>

The rate of C; difficile acquisition is estimated to be 13 percent in patients with hospital stays of up to two weeks and 50 percent in those with hospital stays longer than four weeks; 7 Patients who share a room with a C; difficile-positive patient acquire the organism after an estimated hospital stay of 3; 2 days, compared with a hospital stay of 18; 9 days for other patients; The precipitating event for C; difficile colitis is disruption of the normal colonic microflora; This disruption usually is caused by broad-spectrum antibiotics (Figure 2),1,5,8-11 with clindamycin (Cleocin) and broad-spectrum penicillins and cephalosporins most commonly implicated; 8 Antibiotics with a reduced propensity to induce infection include aminoglycosides, metronidazole, antipseudomonals, and vancomycin; 8 The risk of developing antibiotic-associated diarrhea more than doubles with longer than three days of antibiotic therapy; After disruption of the colonic microflora, colonization of C; difficile generally occurs through the ingestion of heat-resistant spores, which convert to vegetative forms in the colon; 9 Depending on host factors, an asymptomatic carrier state or clinical manifestations of C; difficile colitis develop; Manifestations of the disease range from mild diarrhea to life-threatening C; difficile colitis; C; difficile-associated diarrhea can occur up to eight weeks after the discontinuation of antibiotics; 1 Most cases of C; difficile infection occur on days 4 through 9 of antibiotic therapy; The rate of Clostridium difficile acquisition is estimated to be 13 percent in patients with hospital stays of up to two weeks and 50 percent in those with hospital stays longer than four weeks; -----------------------[AAFP journal/website 2007]----------------------<br>

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