Clostridium Defficile

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Clostridium Defficile:

Clostridium Defficile Presented by Warda Javed Roll # 110

Background and Short History:

Background and Short History C. difficile is an abbreviation of Clostridium difficile and it is the major cause of antibiotic-associated diarrhoea and colitis, an infection of the intestines. It is part of the Clostridium family of bacteria, which also includes the bacteria that cause tetanus, botulism, and gas gangrene. Although C. difficile was first described in the 1930s, it was not identified until the late 1970s as the cause of diarrhoea and colitis following antibiotic therapy.

Characteristics:

Characteristics Anaerobic Gram-positive bacillus Cell Morphology: rod shaped Bacillus Produces exotoxins A and B resistant to most antibiotics Spore forming Spores are ingested - pass through the stomach unscathed due to acid-resistance Change to active form in colon and multiply

Transmission:

Transmission Fecal – oral route Contaminated hands of healthcare workers Contaminated environmental surfaces. Person to person in hospitals C. diff spores can survive for up 5 months on environmental surfaces Spores can survive for days outside of the body and are resistant to common hospital disinfectants

Habitat:

Habitat Gastrointestinal tract of Humans and other animals Soils Marine Sediments Anaerobic aquatic sediments

Pathogenesis:

Pathogenesis Antibiotics supress normal flora Allowing C. defficile to multiply and produce exotoxins A and B Both exotoxins are glucosyltransferases (enzymes that glucosylate a G protein called Rho GTPase ) The main effect of exotoxin B is to cause depolymerisation of actin Resulting in loss of cytoskeletal integrity and Apoptosis Death of the enterocytes .

CDI: Pathogenesis :

7 CDI: Pathogenesis Step 1- Ingestion of spores transmitted from other patients Step 2- Germination into growing (vegetative) form Step 3 - Altered lower intestine flora (due to antimicrobial use) allows proliferation of C. difficile in colon Step 4 . Toxin B & A production leads to colon damage +/- pseudomembrane

Life cycle Of C. Defficile:

C. difficile Reservoir Bowel Environment Infectious Agent C.difficile Means of Transmission Spores left on contaminated hands, equipment or in the environment Portal of entry Faecal/oral Susceptible Host Life cycle Of C. Defficile

ClinicalFeatures:

ClinicalFeatures Diarrhea (watery diarrhoea ) Pseudomembranous Colitis (yellow-white plaques seen on the colonicmucosa ) Fever , Nausea, loss of appetite Abdominal pain Blood if pseudomembranous colitis Electrolyte disturbances Toxic mega-colon Increased abdominal pain Abdominal bloating Abdominal tenderness Fever Tachycardia (rapid heart rate) Dehydration

PowerPoint Presentation:

Normal Colon Colon with PMC due to Clostridium difficile Infection Normal Colon and Pseudomembranous Colitis (PMC) as seen at Colonoscopy

Lab Diagnosis:

Lab Diagnosis Colonoscopy for the presence of pseudomembranes Test for C.difficile toxin in stool Cytotoxicity cell assay (Gold Standard) Expensive, 24 hour turn around time ELISA (enzyme-linked immunosorbent assay) Inexpensive, rapid turn around time 60-90% sensitive with a negative predictive value >95% Repeat testing increases risk of false positive

PowerPoint Presentation:

Pseudomembranous Colitis

How can we manage the problem?:

How can we manage the problem? Treatment Fluid & electrolyte replacement Withdrawal of antibiotic therapy, if possible Antibiotic treatment to eradicate C difficile .

Antibiotic Treatment:

Antibiotic Treatment Disease/host characteristics Recommended therapy Mild disease (no systemic symptoms, only mild diarrhoea) Metronidazole 250 mg by mouth four times a day or 500 mg by mouth three times a day for ten days

Antibiotic Treatment:

Antibiotic Treatment Disease/host characteristics Recommended therapy Mild disease (no systemic symptoms, only mild diarrhoea) Metronidazole 250 mg by mouth four times a day or 500 mg by mouth three times a day for ten days Moderate disease (fever, profuse diarrhoea, abdominal pain, leukocytosis) Vancomycin 125-500 mg by mouth four times a day for ten days

Antibiotic Treatment:

Antibiotic Treatment Disease/host characteristics Recommended therapy Mild disease (no systemic symptoms, only mild diarrhoea) Metronidazole 250 mg by mouth four times a day or 500 mg by mouth three times a day for ten days Moderate disease (fever, profuse diarrhoea, abdominal pain, leukocytosis) Vancomycin 125-500 mg by mouth four times a day for ten days Severe disease (paralytic ileus , toxic megacolon , dehydration or sepsis) Surgical consultation and intraluminal vancomycin

Antibiotic Treatment:

Antibiotic Treatment Disease/host characteristics Recommended therapy Mild disease (no systemic symptoms, only mild diarrhoea) Metronidazole 250 mg by mouth four times a day or 500 mg by mouth three times a day for ten days Moderate disease (fever, profuse diarrhoea, abdominal pain, leukocytosis) Vancomycin 125-500 mg by mouth four times a day for ten days Severe disease (paralytic ileus , toxic megacolon , dehydration or sepsis) Surgical consultation and intraluminal vancomycin Inability to take oral medication Intraluminal vancomycin with or without intravenous metronidazole

Prevention:

Prevention There are no preventions, Vaccines or drugs. Antibiotics should be prescribed only when necessary .

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