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Clostridium difficile infection Clinical presentation and ...


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Clostridium difficile infection Clinical presentation and ...

  1. 1. Clostridium difficileinfectionClinical presentation and complications<br />Dr Vu Kwan<br />Staff Specialist<br />Department of Gastroenterology<br />Westmead Hospital<br />
  2. 2. Case presentation<br />
  3. 3. Mr HL<br />72 year old male<br />Background:<br />Ischaemic heart disease<br />NSTEMI 2009<br />Coronary stent<br />Echocardiogram: EF 25%<br />Atrial fibrillation<br />Warfarin<br />Chronic kidney disease<br />Baseline creatinine ~180<br />
  4. 4. October 2009<br />Per rectum bleeding<br />Admitted for observation<br />Discharged for outpatient colonoscopy<br />Recurrent bleeding<br />Admitted for inpatient colonoscopy<br />Colonoscopy:<br />Multiple large colonic polyps<br />Endoscopic mucosal resection performed<br />Histology <br />Multiple tubular adenomas<br />Invasive malignancy not excluded<br />
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  8. 8. Post-polypectomy<br />Represented 3 days post-procedure with recurrent rectal bleeding<br />ED assessment:<br />“Post-polypectomy bleeding”<br />“Possible peptic ulcer bleeding”<br />Commenced on high dose proton-pump inhibitor infusion<br />Observed for several days  bleeding cessation<br />Discharged home<br />
  9. 9. Representation<br />Represented 2 days later with bloody diarrhoea<br />Up to 10 episodes per day<br />Initially assumed to be ongoing post-polypectomy bleeding<br />No stool tests performed<br />
  10. 10. Colonoscopy<br />Pseudomembranous colitis<br />
  11. 11. History<br />No history of recent antibiotics<br />Only history:<br />Elderly male<br />Multiple co-morbidities<br />Repeated hospitalisations<br />Only new medication = PPI<br />
  12. 12. Progress<br />Commenced on oral metronidazole<br />Ongoing fluid balance problems<br />Dehydration due to diarrhoea<br />Worsening renal function<br />Fluid therapy resulting in pulmonary oedema<br />Prolonged HDU admission with other medical complications<br />Eventual resolution of diarrhoea & discharge 3 weeks later<br />
  13. 13. C.difficile:Overview of clinical aspects <br />
  14. 14. Overview<br />One of the most common healthcare-associated infections<br />Spectrum of disease ranging from asymptomatic carriage to fulminant colitis<br />Commonly a result of antibiotic therapy due to alteration of normal gut flora<br />
  15. 15. Overview<br />Can occur without antibiotic use, importantly via nosocomial transmission<br />Mortality rates of up to~25% reported, particularly in elderly1<br />1. Crogan et al, GeriatrNurs 2007<br />
  16. 16. Clinical aspects<br />
  17. 17. Spectrum of disease<br />
  18. 18. 1. Asymptomatic carriage<br />Approximately 20% of hospitalised patients are C. difficilecarriers<br />Significant reservoir for disease transmission<br />Contribution of host’s immune response is unclear<br />
  19. 19. 2. C.difficilediarrhoea<br />Watery diarrhoea<br />>3 times per day<br />>2 days duration<br />More severe cases<br />Up to 15 motions per day<br />Lower abdominal pain and cramping<br />Low grade fever<br />Leucocytosis<br />Onset may be during antibiotic therapy or 5-10 days after treatment<br />Can present up to 10 weeks after antibiotic cessation<br />
  20. 20. 3. C.difficile colitis<br />More significant illness than diarrhoea alone<br />Constitutional symptoms, fever, abdominal pain + watery diarrhoea<br />Colonoscopy:<br />Non-specific diffuse or patchy erythematous colitis<br />
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  22. 22. 4. Pseudomembranous colitis<br />The classic manifestation of full-blown C.difficile colitis<br />Symptoms similar to, but often more severe than, colitis due to other causes<br />Unwell, WCC, hypoalbuminaemia<br />Colonoscopy:<br />Classical raised white/yellow plaques<br />
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  24. 24. 5. Fulminant colitis<br />Severe manifestation affecting ~3%<br />Account for the most serious complications:<br />Perforation<br />Prolonged ileus<br />Toxic megacolon<br />Death<br />Clinical features of fever, leucocytosis, abdominal distension<br />
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  26. 26. Extracolonic manifestations<br />Small bowel<br />Bacteraemia<br />Reactive arthritis<br />Others<br />
  27. 27. 1. Small bowel<br />Particularly described in small bowel subjected to recent surgery<br />Inflammatory bowel disease post ileal-anal anastomosis<br />Pseudomembrane formation<br />May act as a reservoir for recurrent colonic infection?<br />
  28. 28. 2. Bacteraemia<br />Uncommon<br />Associated with high mortality rate1<br />May be more common in patients with underlying gastrointestinal diseases2<br />Daruwala et al, Clin Med Case Reports 2009<br />Libby et al, Int J Infect Dis 2009 <br />
  29. 29. 3. Reactive arthritis<br />Polyarticular arthritis<br />Knee and wrist in 50% of cases<br />Onset average 11 days after diarrhoea1<br />Prolonged illness : average 68 days to resolve2<br />Birnbaum et al, ClinRheumatol 2008<br />Jacobs et al, Medicine (Baltimore) 2001<br />
  30. 30. 4. Other extracolonic manifestations <br />Cellultis<br />Necrotisingfasciitis<br />Osteomyelitis<br />Prosthesis infection<br />Intra-abdominal abscess<br />Empyema<br />etc<br />
  31. 31. Risk factors<br />
  32. 32. Risk factors<br />General risk factors<br />Long duration antibiotics<br />Multiple antibiotics<br />Nature of faecal flora<br />Production of requisite cytotoxins<br />Presence of host risk factors<br />Specific risk factors<br />Immunosuppressive drugs<br />Gastric acid suppression<br />Cancer chemotherapy with antibiotic properties<br />
  33. 33. Host risk factors<br />Advanced age<br />Nasogastric tube<br />Severe underlying illness<br />Prolonged hospitalisation<br />Enema therapy<br />GI stimulants<br />Stool softeners<br />
  34. 34. Inflammatory bowel disease<br />Chronic, relapsing inflammatory disorders of the bowel of unknown aetiology<br />Ulcerative colitis<br />Crohn’s disease<br />Enteric infections account for ~10% of ‘relapses’<br />C.difficile in about half<br />May mimic a relapse, OR trigger a true relapse<br />
  35. 35. Inflammatory bowel disease<br />Crucial that C.difficile is considered in the differential diagnosis of every ‘flare’<br />Otherwise inappropriate escalation of immunosuppression may result in severe infection<br />High index of suspicion required as classical pseudomembranes don’t form in IBD<br />Treatment is to REDUCE their usual immunosuppressive drugs<br />
  36. 36. Gastric acid suppression<br />
  37. 37. Gastric acid suppression<br />Gastric acid inhibits germination of ingested C.dificile spores<br />Therefore, medications lowering gastric acid could increase risk of C.difficile infection<br />Clinical data are conflicting<br />
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  39. 39. Imaging investigations<br />
  40. 40. Imaging investigations<br />Abdominal xray<br />CT scan<br />Colonoscopy<br />
  41. 41. Abdominal xray<br />Important in patients who are unwell with C.difficile infection<br />Findings:<br />Ileus<br />Toxic megacolon<br />Perforation<br />
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  43. 43. CT scan<br />Diagnosis can often be made on CT alone<br />Several characteristic findings:<br />Gross bowel wall thickening<br />Luminal narrowing<br />Characteristic signs:<br />“Accordion sign”<br />“Target sign”<br />
  44. 44. CT scan<br />
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  47. 47. Colonoscopy<br />Pathognomonic appearance of pseudomembranes<br />Raised, white/yellow plaques<br />Up to 1/3 right-sided only, so full colonoscopy better than sigmoidoscopy<br />Biopsies reveal spectrum of mucosal inflammation and necrosis<br />
  48. 48. Colonoscopy<br />
  49. 49. Colonoscopy<br />Beware colonoscopy in unwell patients with ileus or megacolon<br />Risk of perforation<br />If clinical picture and stool tests are suggestive, minimal role for colonoscopy <br />
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  51. 51. Conclusion<br />Health-care associated infection of great clinical significance<br />Spectrum of disease ranging from asymptomatic infection to fuliminant colitis and death<br />Imaging investigations are complimentary to clinical index of suspicion<br />
  52. 52. Recurrent C.difficile infection<br />Approximately 15-20% of patients with CDAD relapse following successful treatment<br />One relapse predicts further relapses!<br />Sudden recurrence of diarrhoea within ~1 week of treatment cessation<br />