C Diff colitis

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Mohamed Shehata, MD Clinical Assistant Professor of Medicine Baylor College of Medicine Hosuton.TX

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C. Diff. Colitis :

C. Diff. Colitis A case of Diarrhea American Board Certified Doctors for Egypt Mohamed Shehata,M.D. Assistant Professor of Medicine Baylor College of Medicine Member of the American College of Medicine Member of the American Geriatrics society

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c/o severe 10/10 abdominal pain, Diarrhea and weight loss for more than 6 months. HPI: 23 y o F patient with h/o nausea, non bloody vomiting , abdominal pain, watery stool and 60 lb. weight loss over last year all s/s are worse by eating.

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Patient had just had a negative colonoscopy and EGD with negative pathology. Has been treated in the past for IBS, but now treatment is ineffective in controlling her symptoms and was sent to the ER for hospitalization by her doctor, on admit she is very upset and wants to see a different gastroenterologist.

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P.E: General: very anxious, tearful from stress and pain, thin body built. Well developed. HEENT: NO JVD, No Pallor, No Icterus C.V.S: S1S2 RRR. No gallop, No murmur. Pulmonary: Clear to Auscultation and percussion. No wheezing and no crackles Continue………

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Abdomen: Soft, diffusely tender worse at epigastric area and mid abdomen. increased bowel sounds, no rebound, no guarding. Extremities: No pedal edema, intact pedal pulses, no cyanosis, no clubbing.

workup :

workup Patient had Ct. with and without contrast from the ER, that was completely normal with no abnormality ( colon, GB,spleen,stomach , SI, Liver) Labs: CBC, BMP, liver profile, prealbumin,magnesium Abdominal X-ray no ileus no SBO.

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C. Diff stool test: detected. Patient was started on Flagyl 500 mg IV q8H -hydrocodone 5 mg tablets every 6 hours -IVF for treatment of dehydration. -anti-emetics and PPI, -C. Diff. contact isolation. Patient was discharged home on flagyl tablets for total of 2 weeks after contact isolation and hygiene education on hand wash with soap and water.

Incidence:

Incidence Community acquired Health care Related

Scope of the problem:

Scope of the problem Dramatic increases in the incidence and severity of healthcare-associated C. difficile infection have occurred over since 2000, particularly in patients over age 65. As an example, the rate of nosocomial C. difficile-associated diarrhea (CDAD) in the United States doubled from 31 per 100,000 to 61 per 100,000 between 1996 and 2003. The rate was significantly higher in patients older than 65 (228 per 100,000). These cases were more serious and refractory to therapy with significant rates of toxic megacolon and disease requiring colectomy . Ten percent of cases required admission to an intensive care and 2.5 percent underwent an emergency colectomy; the mortality was 16 percent .

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C. difficile carriage occurs in 20 to 50 percent of adults in hospitals and long term care facilities ( the carrier rate among healthy adults is about 3 percent) . About 20 percent of patients with negative admission stool cultures become infected during their hospitalization

Transmission modes::

Transmission modes: C difficile is highly transmissible via fomites and can be cultured readily from nearly any surface, including items in patient rooms as well as the hands, clothing, and stethoscopes of health care workers. Infection is also transmitted readily between hospital roommates.

Risk factors: :

Risk factors: 1-Antibiotics Antimicrobial agents that may induce clostridium difficile diarrhea and colitis Frequently associated : Fluoroquinolones Clindamycin Penicillins (broad spectrum) Cephalosporins (broad spectrum ) The use of broad-spectrum antimicrobials, use of multiple antibiotic agents, and increased duration of antibiotic therapy all contribute to the incidence of CDAD

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Occasionally Asociated : Macrolides,Trimethoprim , Sulfonamides. Rarely associated : Aminoglycosides,Tetracyclines,Chloramphenicol,Metronidazole,Vancomycin.

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2-Advanced age: 228/100.000 for age above 65 y o 3-Gastric acid suppression : PPI related acid suppression may be associated with an increased risk of C. difficile -associated diarrhea 4-Community-associated infection : cases in a Minnesota county from 1991 through 2005 increased dramatically over this period of time to be 41% 5- enteral feeding, gastrointestinal surgery, cancer chemotherapy and hematopoietic stem cell transplantation

MICROBIOLOGY:

MICROBIOLOGY Clostridium difficile is an anaerobic gram-positive, spore-forming, toxin-producing bacillus first described in 1935 spores are resistant to heat, acid and antibiotics. Once spores are in the colon, they convert to their fully functional vegetative, toxin-producing forms and become susceptible to killing by antimicrobial agents. Toxin A causes inflammation leading to intestinal fluid secretion, mucosal injury and inflammation. Toxin B is essential for the virulence of C. difficile, and is approximately ten times more potent than toxin A on a molar basis for mediating colonic mucosal damage.

Clinical variants of C. difficile infection:

Clinical variants of C. difficile infection 1-Asymptomatic Carriage: No Diarrhea, No abdominal pain. Physical Exam: Normal Sigmoidoscopy : Normal

2-C. Diff associated Diarrhea with Colitis: :

2-C . Diff associated Diarrhea with Colitis: Fecal leukocytes present. Occult bleeding may be seen. Hematochezia rare. Nausea, anorexia, fever, malaise, dehydration, leukocytosis with left shift. Abdominal distention, tenderness. Diffuse or patchy nonspecific colitis

3-Pseudomembranous colitis:

3-Pseudomembranous colitis • Diarrhea more profuse than in colitis without pseudomembranes . Fecal leukocytes present. Occult bleeding may be seen. Nausea, anorexia, fever, malaise, dehydration, leucocytosis with left shift; symptoms may be more severe than in colitis without pseudomembranes

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Marked abdominal tenderness, distension. Sigmoidoscopy : Characteristic raised, adherent, yellow plaques, diameter up to 2 cm; rectosigmoid spared in 10 percent of cases; pseudomembranes may not be noted unless colonoscopy performed

Fulminant colitis:

Fulminant colitis Diarrhea may be severe OR diminished (due to paralytic ileus and colonic dilatation ) • Surgical consult required; colectomy can be life-saving Lethargy, fever, tachycardia, abdominal pain; dilated colon/paralytic ileus may be demonstrated on plain abdominal film May present as acute abdomen; peritoneal signs suggest perforation Sigmoidoscopy and colonoscopy contraindicated; flexible proctoscopy with minimal air insufflation may be diagnostic

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Manifestations of C. difficile-associated diarrhea (CDAD) with colitis include watery diarrhea up to 10 or 15 times daily with lower abdominal pain and cramping, low grade fever, and leukocytosis.

Relapse/Reinfection:

Relapse/Reinfection Relapse or reinfection develops in 10-25% Diarrhea may be less prominent in patients with prolonged ileus due to pooling of secretions in the dilated, atonic colon. Potential complications include toxic megacolon and bowel perforation.

Diagnosis:

Diagnosis Should be based on results from a laboratory diagnostic test detecting toxin-producing Cd strains or an endoscopic evaluation that demonstrates pseudomembranes in the colon. 1-Anaerobic stool culture is the most sensitive test but is not practical due to its slow turnaround time. 2-Cytotoxicity assay also takes too long for routine clinical use but is the standard against which other clinical tests should be compared to. 3-Enzyme immunoassay (EIA) testing for C. difficile toxins A and B, which is rapid but less sensitive than the cytotoxicity assay. 4-Polymerase chain reaction (PCR) of stool appears to be rapid, sensitive, and specific; major clinical laboratories are beginning to adopt this tool as their primary diagnostic approach

•Treatment :

•Treatment cessation of the inciting antibiotic . Hand Hygiene/contact isolation. Non-severe cases : Flagyl Severe cases : P.O V ancomycin 125 mg po q6h for 10-14 days Severe and resistant to improve on smaller dose P.O V ancomycin increase dose to 500 mg P.O q6h. Patients who can not tolerate V ancomycin can be tried on Fidaxomycin

recurrence:

recurrence for none severe Initial Recurrence of CDAD We suggest oral metronidazole F or 2nd recurrence We suggest intermittent and tapering vancomycin therapy For treatment of subsequent recurrences of CDI, we suggest administering either vancomycin followed by rifaximin , or fidaxomicin

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•Surgical evaluation for patients ≥65 years of age with a white blood cell count ≥20,000 cells/ microL and/or a plasma lactate between 2.2 and 4.9 meq /L. Surgical intervention is advisable in the setting of peritoneal signs, severe ileus, or toxic megacolon . Potential alternative therapies requiring further investigation prior to routine use include new antibiotic agents, binding resins, intravenous immunoglobulin, and fecal bacteriotherapy

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there is insufficient data for sue of vaccination,use of probiotics and value of treatment of asymptomatic carriers Antibiotic restriction can reduce C. difficile rates; strategies for antibiotic use should be tailored to health care delivery in particular institutions. Prevention and control of CDI in healthcare settings requires careful attention to hand hygiene, contact precautions, and environmental cleaning

Hand wash:

Hand wash The importance of duration of handwashing was illustrated in a study in which vancomycin -resistant enterococci (VRE) were inoculated onto the hands of healthy volunteers . A 30-second wash with water plus soap was necessary to completely eradicate VRE hand carriage. In contrast, a 5-second wash with water alone produced virtually no change in VRE recovery

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