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Thread: Clostridium difficile diarrhea

  1. #1

    Clostridium difficile diarrhea

    In another topic in the Cure Forum, a question was raised about C. difficile. I have heard from several people that they had C. difficil infections this summer and thought that it might be useful to summarize the condition.

    This bacterium causes a foul-smelling watery diarrhea that may contain blood and mucus, as well as abdomenal cramps. These symptoms result from a toxin that is produced by the bacterium. C. difficile enterocolitis is is a remarkably common disease. Buchner & Sonnenberg (2001) found over 15,000 cases in the VA system recorded between 1993-1998. When this was extrapolated by condition, they estimated that there may have been over 136,840 cases.

    C. difficile infections usually arise when people take broad-spectrum antibiotics that disturb the normal intestinal flora. The bacterium does not compete well in the presence of normal intestinal flora and tends to show up when people are taking broad-spectrum antibiotics for treating other conditions. Because the infection occurs in patients who are taking broad-spectrum antibiotics (such as lincomycin, clindamycin, cephalosporins, ciprofloxacin), C. difficile is often antibiotic resistant. It also occurs in people who take quinolone. Note, however, that C. difficile is a normal part of the intestinal flora of babies less than a year of age. About 5% of people normally carry the bacterium.

    Treatment is with metronidazole or vancomycin (both of these may be quite debilitating). But these sometimes do not work and many other medications have been tried without success http://www.cdiffsupport.com/database.html. Probiotic treatments are recommended for C. difficile infections (Elmer, 2001), including lactobacillus acidophilus, bididobacterium longum, or enterococcus faecium.

    In some people, C. difficile may become a chronic infection and is a serious disease. There is even a support group for people with C. difficile infections. Because the bacterium is a spore-former, transmission is usually via an fecal-oral route. While a variety of anti-infectants will kill the spores, they can survive up to 70 days in the environment and can be transported on the hands of health personnel.

    Non-intestinal forms of C. difficile infections include arthritis and septicemia (blood infection). I was unable to find much information concerning C. difficile infections of the urinary tract. It is true that the bacterium is hard to culture (hence its name) and is not commonly reported in urinary cultures. However, there are simply no reports of the bacterium participating in urinary tract infections, except where intestine was used to create a bladder reservoir (Mathai, et al., 2002). C. difficile causes high white blood cell counts (leukocytosis), accounting for 25% of patients with WBC counts >30,000 cells/mm. If a person has a WBC count >15,000, C. difficile should be considered as a cause (Wanahita, et al., 2002).

    Wise.

    Links and References
    See http://healthlink.mcw.edu/article/954992292.html
    http://www.aboutibs.org/Publications/CDifficile.html
    http://www.cdiffsupport.com/
    http://www.amm.co.uk/pubs/fa_cdiff.htm
    http://hopkins-id.edu/icaac/icaac_cd.html#quino


    • Mathai MG, Shanthaveerapa HN, Byrd RP, Jr. and Roy TM (2002). Fatal pseudomembranous colitis in a continent urinary neobladder. J Ky Med Assoc 100:234-7. Summary: Antibiotic-associated colitis is a significant clinical problem, especially in patients hospitalized for longer than three days. Clostridium difficile is now established as the most common nosocomial enteric pathogen causing antibiotic-associated colitis. The condition rarely occurs beyond the boundaries of the large bowel, but can represent significant diagnostic and therapeutic problems if it involves bowel that is used in the creation of a diversionary reservoir such as an ileo-cecal neobladder. We present what we believe to be the first reported case of fatal pseudomembranous colitis occurring in an ileo-cecal neobladder. Veterans Affairs Medical Center, 111-B, PO Box 4000, Mountain Home, TN 37684-4000, USA.


    • Wanahita A, Goldsmith EA and Musher DM (2002). Conditions associated with leukocytosis in a tertiary care hospital, with particular attention to the role of infection caused by clostridium difficile. Clin Infect Dis 34:1585-92. Summary: Few modern studies have enumerated the conditions associated with leukocytosis. Our clinical experience has implicated Clostridium difficile infection in a substantial proportion of patients with leukocytosis. In a prospective, observational study of 400 inpatients with WBC counts of >/=15,000 cells/mm(3), we documented >/=1 infection in 207 patients (53%). Of these 207 patients, 97 (47%) had pneumonia, 60 (29%) had urinary tract infection, 34 (16%) had soft-tissue infection, and 34 (16%) had C. difficile infection. C. difficile infection was present in 25% of patients with WBC counts of >30,000 cells/mm(3) who did not have hematological malignancy. Other causes of leukocytosis in the 400 patients included physiological stress, in 152 patients (38%); medications or drugs, in 42 (11%); hematological disease, in 22 (6%); and necrosis or inflammation, in 22 (6%). C. difficile infection is a prominent cause of leukocytosis and this diagnosis should be considered for patients with WBC counts of >/=15,000 cells/mm(3), even in the absence of diarrheal symptoms. Infectious Disease Section, Medical Service, Veterans Affairs Medical Center, Houston, TX, 77030, USA. daniel.musher@med.va.gov


    • Elmer GW (2001). Probiotics: "living drugs". Am J Health Syst Pharm 58:1101-9. Summary: The uses, mechanisms of action, and safety of probiotics are discussed. Probiotics are live microorganisms or microbial mixtures administered to improve the patient's microbial balance, particularly the environment of the gastrointestinal tract and the vagina. The yeast Saccharomyces boulardii and the bacterium Lactobacillus rhamnosus, strain GG, have shown efficacy in clinical trials for the prevention of antimicrobial-associated diarrhea. Other probiotics that have demonstrated at least some promise as prophylaxis for this type of diarrhea are Lactobacillus acidophilus, Bifidobacterium longum, and Enterococcus faecium. The use of S. boulardii as an adjunctive treatment to therapy with metronidazole or vancomycin has been found in controlled studies to decrease further recurrences of Clostridium difficile-associated disease. Other gastrointestinal disorders for which probiotics have been studied include traveler's diarrhea, acute infantile diarrhea, and acute diarrhea in adults. Several Lactobacillus species given in yogurt or in tablet or suppository form have shown clinical efficacy as a treatment for vaginal infections. Lactobacillus strains have also been examined as a treatment for urinary-tract infections. Putative mechanisms of action of probiotics include production of pathogen-inhibitory substances, inhibition of pathogen attachment, inhibition of the action of microbial toxins, stimulation of immunoglobulin A, and trophic effects on intestinal mucosa. The available probiotics are considered nonpathogenic, but even benign microorganisms can be infective when a patient is severely debilitated or immunosuppressed. Probiotics have demonstrated an ability to prevent and treat some infections. Effective use of probiotics could decrease patients' exposure to antimicrobials. Additional controlled studies are needed to clearly define the safety and efficacy of these agents. Medicinal Chemistry, School of Pharmacy, University of Washington, Box 357610, Seattle, WA 98195, USA. elmer@u.washington.edu

    • Buchner AM and Sonnenberg A (2001). Medical diagnoses and procedures associated with clostridium difficile colitis. Am J Gastroenterol 96:766-72. Summary: OBJECTIVES: The aim of this study was to examine the associations of Clostridium difficile colitis with other comorbid conditions and procedural interventions among hospitalized patients. METHODS: The Patient Treatment File of the Department of Veterans Affairs contains the computerized records of all inpatients treated in 172 Veterans Affairs hospitals distributed throughout the United States. The computerized medical records of 15,091 cases with C. difficile colitis and 61,931 controls without the diagnosis were extracted from the annual files between 1993 and 1998. In a multivariable logistic regression, the occurrence of C. difficile colitis served as outcome variable, whereas the occurrences of other diagnoses or procedures served as predictor variables. RESULTS: The total numbers of diagnoses in the case and control group were 136,840 and 465,972, respectively. The numbers of procedures were 75,479 and 129,612, respectively. C. difficile colitis was significantly associated with HIV infection, candidiasis, malignant neoplasm and chemotherapy, malnutrition, pneumonia, aspiration pneumonitis, intestinal obstruction, diverticulitis, renal failure, urinary tract infection, decubitus, and osteomyelitis. Interventional procedures involving the respiratory tract, bone marrow biopsy, arterial and venous catheterization, urinary catheterization, dialysis, gastrostomy tube, and physical therapy were also frequently associated with the development of C. difficile colitis. CONCLUSIONS: These associations reflect the influence of causal relationships (such as the use of antibiotics and chemotherapy), an increased risk of exposure to C. difficile among immobilized bedridden patients with chronic disease states, or a general system failure in patients with end-stage disease. Knowledge of such associations could help to alert physicians to an increased risk of C. difficile colitis among particular groups of susceptible patients. Department of Veterans Affairs Medical Center, and The University of New Mexico, Albuquerque 87108, USA.

  2. #2
    Guest
    Thanks for the information, Wise.

    While I was in rehab I would get a UTI, they would treat it with an antibiotic, and C. diff would come. This happened about 4 times. A couple of times it got where I couldn't eat or drink without vomitting. I had to have an IV of fluids once because of dehydration.

    I remember being treated with oral vancomycin. I think they also tried treating it with Flagil(sp?) once?

  3. #3
    Senior Member Jeff's Avatar
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    Wow, cjo - that was an institutionally acquired infection. I wonder if you would have had the same problem being out in the community. I've taken broad spectrum antibiotics a million times and never had what you describe. Things that make you go "hmmmm..."

    ~See you at the SCIWire-used-to-be-paralyzed Reunion ~

  4. #4
    Guest
    Believe me Jeff, it was hell. I definitely attribute it to the institution. The first month I was there I had no problems. The next two months they moved me to a different wing and the problems started. Needless to say, I don't think I got the full benefit from rehab at the top notch SCI center I was at. But, they sent me home anyway.

  5. #5
    I also had this infection during my hospital stay and rehab. It took about a total of 6 weeks to kick. In fact, I was released from the rehab hospital to home (finally) and had to be rushed back to the hospital within a week because of a reoccurrence. I had high fevers and my white blood cell counts were excessively high. They said I could have gone into toxic shock with the levels they were at.

    Bad memories...

    Edited to say that I was treated with Flagil also...

  6. #6
    cjo, you have a great memory. Flagyl is metronidazole. Wise.

  7. #7

  8. #8
    i believe i had this problem...on and off from january to july until i had to be hospitalized because it was just non stop, even if i drank a few gulps of water. in the beginning i was told to just increase my fiber intake. while in the hospital, the doctor told me it was just something i ate, but i knew there had to be more to it. he said blood and mucous is normal with dysentary (which was the diagnosis)...is this true? i never heard any AB having such serious issues. i had a UTI too. it got really bad after i was on an oral antibiotic at home. after i was admitted, they gave me levaquin (sp?) through an IV and it eventually stopped. it was absolutely miserable!! thanks for posting this, at least now i know what i had.

    ~~Everyone wants to change the world, but nobody wants to change himself. ~Leo Tolstoy~

  9. #9
    I can definitely testify to the effectiveness of a lactobaccillus supplement. I take them every time I go on antibiotics now.

  10. #10
    I am currently going through a reoccurance of c.diff. I was originally on metronidazole for something unrelated and ended up contracting c.diff. i just started taking probiotics to see if this will help. The strange part is that i have a resistant strain of c.diff to metronidazole, it has baffled the lead specialists of infectious disease at my local hospital... any words of wisdom???

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