Clostridium difficile infection history and symptoms
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Often clinicians begin treatment before results have come back based on clinical presentation to prevent complications. Knowledge of the local epidemiology of intestinal flora of a particular institution can guide therapy.
In adults, a clinical prediction rule found the best signs are[1] :
- significant diarrhea ("new onset of > 3 partially formed or watery stools per 24 hour period")
- exposure of antibiotics
- abdominal pain
- foul stool odor
The presence of any one of these findings has a sensitivity of 86% and a specificity of 45%.[1] In this study of hospitalized patients with a prevalence of positive cytotoxin assays of 14%, the positive predictive value was 20% and the negative predictive value was 95%.
History and Symptoms
Clinical manifestations can be quite variable. Some patients are asymptomatic, and others can present critically ill with toxic megacolon.
- Up to 2/3 of infected hospitalized patients are asymptomatic, but shed organisms and contaminate their environment. These patients are called C. Diff fecal excretors. These patients can be treated with vancomycin or metronidazole, but the bug is often not eradicated in these patients.
- The reason for the variability is not clear and is not accounted for by strain differences. Host factors are probably important, such as the presence of antitoxin antibodies and colonic toxin receptors.
- Risk factors for severe colitis include malignancy, Chronic Obstructive Pulmonary Disease (COPD), immunosuppression, renal failure, exposure to anti-peristaltic meds and clindamycin.
- Onset is usually during or shortly after a course of antibiotics. Cases rarely occur even a month after a course of antibiotics. Rarely patients have no recent history of antibiotics.
Antibiotic-associated diarrhea with C. diff infection, but without colitis may present as:
- Acute, foul-smelling watery diarrhea, with a mean of 3-4 stools a day.
- Lower abdominal pain, sometimes crampy
- Low-grade fever
Antibiotic-associated diarrhea with C. diff infection with colitis but without pseudomembrane development may present as:
- Profuse, watery diarrhea of 5-15 bowel movements daily
- Fever
- Malaise
- Anorexia
- Lower quadrant abdominal pain and cramps, relieved by the passage of diarrhea.
- Nausea
- Dehydration
- Leucocytosis
- Fecal leucocytes present in >50%. Occult bleeding not uncommon.
- Sigmoidoscopy shows a nonspecific diffuse or patchy erthrematous colitis without pseudomembranes.
Antibiotic-associated diarrhea with C. diff infection with colitis and pseudomembrane development presents with prominent signs and symptoms as described above and sometimes:
- Rarely patients will develop indolent, subacute pseudomembranous colitis with a protein-losing state due to the diffuse pancolitis. Patients may have severe hypoalbuminemia, ascites, peripheral edema, and their only signs/symptoms may be low-grade fever, anorexia and abdominal discomfort.
- Sigmoidoscopy shows pseudomembranes; raised yellow or off-white plaques ranging up to 1 cm in diameter scattered over the colorectal mucosa. Occasionally pseudomembranes will be located in the proximal colon.
Fulminant colitis is an uncommon complication that occurs in 2-3% of patients with C. Diff, and can results in perforation, prolonged ileus, megacolon, and death. Patients may present with:
- Severe abdominal pain and distension
- Severe diarrhea; diarrhea may be absent in patients with ileus
- Fever, chills
- Lethargy
- Tachycardia
- Leucocytosis, up to 40,000 mm3
- Metabolic acidosis
Toxic megacolon is an enlarged, dilated colon >7cm associated severe systemic toxicity. It may also present with:
- Small intestinal dilation
- Air-fluid levels
- Submucosal edema resulting in thumb-printing