Clostridium difficile

see also:

• clinically important bacteria
• gastroenteritis
• botulism
• Australian Healthcare Special Interest Group
• Clinical practice guidelines - USA

• Clostridium difficile is a Gram positive, anaerobic, heat-resistant spore forming bacillus which is a common cause of antibiotic-related nosocomial colitis, and in its severe form, pseudomembranous colitis.
• it is present in 2-3% of normal adults and in 70% of healthy infants
• ~20% of patients who are hospitalised acquire this organism, and ~1/3rd of these develop diarrhoea.
• it should be suspected as the cause of diarrhoea in any patient who has had antibiotics in the previous 2 months, or if diarrhoea develops after 72 hours of hospitalisation.
• most patients recover without specific treatment, but mortality rates of up to 25% occur in the frail elderly.
• pathogenic strains produce two toxins - Toxin A is an enterotoxin, while Toxin B is a cytotoxin.
• a hypervirulent strain (NAP/027) has spread through Nth America and Europe since 2003, and in 2010 has reached Australia

• broad spectrum antibiotic use
• immunosuppressants
• gastric acid suppression eg proton pump inhibitors (PPIs), or gastrectomy
• prolonged hospitalisation
• elderly
• renal impairment
• non-steroidal anti-inflammatory drugs (NSAIDs)

• avoidance of unnecessary antibiotics or hospitalisation
• strict adherence to infection control such as hand washing
• isolate patients who are incontinent with diarrhoea
• environmental cleaning with sodium hypochlorite solution
• avoid using diclofenac non-steroidal anti-inflammatory agent as this seems to increase risk by 35% ¹⁾
• proton pump inhibitors (PPIs) appear to almost double the risk (1.7x) ²⁾

• rapid stool testing kits are available
• the EIA tests are only 80% sensitive, thus a negative result does not exclude serious disease
  • detect C. difficile glutamate dehydrogenase (GDH) or toxins A or B
• the much more expensive PCR test is more sensitive

• age > 60 years
• temp > 38.3 deg C
• serum albumin < 25 g/L
• peripheral WCC > 15,000 cells/microL
• deteriorating renal function
• elevated serum lactate
• endoscopic evidence of pseudomembranous colitis or ICU Rx
• subtotal colectomy performed
• toxic megacolon

• cease aetiologic antibiotics if possible
• oral or NGT metronidazole tds for 10 days, if not tolerated, can be given iv
• it would appear the most effective Rx is a faecal transplant - faeces from a healthy donor is placed in the colon. This appears to resolve even chronic cases within 24 hours! - see news story
• severe cases may need oral or NGT (NOT iv as not effective) vancomycin 6hrly for 10 days +/- iv metronidazole tds 10 days
• see therapeutic guidelines for more detailed Mx.