Diagnosis and Management of Clostridium Difficile Infection (CDI)
Infection due to Clostridium difficile is a prevalent cause of morbidity and mortality in the intensive care unit. Appropriate diagnosis and treatment of CDI remains challenging in the face of new methods of detection and emerging management strategies. W
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Paul C. Johnson, Christopher F. Carpenter, and Paul D. Bozyk
Case Presentation A 75 year old Caucasian male presented to the hospital with 1 week history of watery diarrhea, five to six episodes daily, accompanied by progressive weakness. Three weeks prior to onset of symptoms, he was admitted for acute exacerbation of chronic obstructive pulmonary disease and was treated with a 5-day course of moxifloxacin and systemic steroids. On presentation he had no leukocytosis (7.0) but had acute kidney injury with a creatinine of 3.6 compared to his baseline of 1.0. Question What is the patient’s most likely diagnosis?
with fluid resuscitation. Over the first several days of admission he had persistent watery stools, about six episodes daily associated with abdominal distension. Infectious Diseases was consulted given lack of improvement and development of leukocytosis (13.5), and vancomycin was increased to 500 mg PO q6h with addition of metronidazole 500 mg IV q8h. Despite this escalation of antibiotic therapy, he developed worsening abdominal distension and hypotension requiring vasopressor support. CT abdomen/pelvis was performed, demonstrating diffuse colonic dilatation with multiple air-fluid levels, consistent with toxic megacolon (Figs. 66.1, 66.2, and 66.3). He underwent total colectomy with end ileostomy and subsequently stabilized.
Answer Clostridium difficile diarrhea. PCR testing for toxigenic Clostridium difficile returned positive, and he was started on vancomycin 125 mg PO q6h. He had borderline hypotension initially, with some improvement
P.C. Johnson (*) Section of Infectious Diseases and International Medicine, Beaumont Hospital, Royal Oak, MI, USA e-mail: [email protected] C.F. Carpenter Section of Pulmonary, Critical Care, and Sleep Medicine, Beaumont Hospital, Royal Oak, MI, USA P.D. Bozyk Medical Intensive Care Unit, Department of Medicine, Beaumont Hospital, Royal Oak, MI, USA
Principles of Management Symptoms of C. Difficile Infection Patients may present with a wide range of clinical manifestations, varying from asymptomatic carriage to shock and colon perforation. Asymptomatic carriage is more frequent than previously thought, ranging geographically from 4.4 to 23.2 % of patients admitted from the community [1]. Watery diarrhea, with or without the presence of mucus, is the classic presenting symptom, but patients may eventually progress to colitis, megacolon, and shock. Significant neutrophilic leukocytosis and acute kidney injury are commonly found with severe disease.
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_66
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Fig. 66.3 Axial view CT abdomen
Fig. 66.1 Plain abdominal film
gene nucleic acid amplification tests, direct culture, and detection of glutamate dehydrogenase. Toxigenic assay method is preferred, as some patients may be asymptomatic carriers [3]. Direct visualization of pseudomembranes can be performed, however the specificity is low for C.
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