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Key Features

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Essentials of Diagnosis
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  • Infection leads to a spectrum of clinical disease, from asymptomatic colonization to severe pseudomembranous colitis with fever, severe abdominal pain, and bloody diarrhea

  • Risk factors for C difficile disease

    • Previous antibiotic use

    • Presence of various chronic diseases, such as immunodeficiency, cystic fibrosis, Hirschsprung disease, inflammatory bowel disease

    • Oncologic treatments

    • Solid-organ transplantation

    • Hospitalization

  • Community-acquired C difficile disease in healthy persons is increasing in incidence

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General Considerations
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  • C difficile is a spore-forming gram-positive bacillus

  • Causes human disease via the secretion of enterotoxins that cause necrotizing inflammation of the colon

  • Interestingly, asymptomatic C difficile colonization of the human gastrointestinal (GI) tract occurs commonly in infants and can occur in older children and adults as well

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Clinical Findings

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  • Characteristics of pseudomembranous colitis

    • Fever

    • Abdominal distention

    • Tenesmus

    • Diarrhea

    • Generalized abdominal tenderness

  • Chronic presentations with low-grade fever, diarrhea, and abdominal pain have been described

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Diagnosis

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Laboratory Findings
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  • Diarrheal stools contain sheets of neutrophils and sometimes gross blood

  • Use of real-time polymerase chain reaction (PCR) for toxin identification has been replacing more traditional enzyme immunoassay (EIA) methods of stool toxin detection because of improved sensitivity

  • C difficile can be cultured in specialized laboratories

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Imaging
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  • Plain abdominal radiographs show a thickened colon wall and ileus

  • On endoscopy, the colon appears to be covered by small, raised white plaques (pseudomembranes) with areas of apparently normal bowel in between

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Diagnostic Procedures
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  • Biopsy specimens show "exploding crypts or volcano lesion"—an eruption of white cells that appears to be shooting out of affected crypts

  • Stool cultures often show overgrowth of Staphylococcus aureus, which is probably an opportunistic organism growing in the necrotic tissue

  • Interpretation of C difficile diagnostic testing in infants remains controversial because asymptomatic colonization is well recognized in the first year of life

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Treatment

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  • Standard treatment of pseudomembranous colitis

    • Discontinue antibiotics

    • Start oral metronidazole (30 mg/kg/d) or vancomycin (30–50 mg/ kg/d)

      • Metronidazole can be given intravenously in patients with vomiting or ileus

      • Vancomycin is many times more expensive than metronidazole and no more efficacious

  • Rifaximin and nitazoxanide

    • Alternative options

    • Both show similar response rates as oral vancomycin

  • Same antibiotic regimen is usually effective in managing relapses

  • Fecal bacteriotherapy, known popularly as fecal transplantation, is now a widely accepted and nearly 100% effective treatment for the treatment of recurrent C difficile infection in adults but experience remains limited in children

  • Adjunctive strategies have been used for refractory disease

    • Saccharomyces boulardii probiotic therapy

    • Cholestyramine as a toxin-binder

    • Pulsed courses of antibiotics

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Outcome

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Prognosis
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  • Incidence, morbidity, and mortality of C difficile has increased in Europe, Canada, and the United States

  • At least a portion of this increase seems ...

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