Clostridium Difficile Colitis Follow-up

• The development of dehydration, electrolyte disturbances, and worsening clinical condition may necessitate inpatient management.

C difficile is now recognized as a major nosocomial pathogen, and universal precautions should be implemented. The following guidelines are recommended when dealing with patients with C difficile colitis:

• Use disposable gloves, laboratory coats, and proper washing techniques.
• Educate the medical and nursing staff regarding the disease and its epidemiology.
• The mode of hospital transmission is unclear, but spores survive on inanimate objects. Therefore, close attention to cleanliness and disinfective measures are important.
• Isolation of patients who are infected is recommended but is often impractical at most hospitals.
• More aggressive control measures, such as treatment of asymptomatic carriers, might be considered in a severe epidemic.

The most important preventive measure is judicious use of antimicrobial agents.

• Fulminant colitis is a rare form of C difficile infection, occurring in only 3% of patients but accounting for most of the serious complications. These include toxic megacolon, colonic perforation, and death. Surgical intervention may be required. Sailhamer et al conducted a retrospective review of nearly 4800 records of 4796 C difficile colitis patients, of which 199 (4.1%) had fulminant C difficile colitis, as defined by the need for colectomy or admission to the intensive care unit for C difficile colitis.^[6] The inhospital mortality rate for fulminant C difficile colitis was 34.7%.The investigators determined independent predictors of mortality included: (1) age 70 years or older, (2) severe leukocytosis or leukopenia or bandemia, and (3)cardiorespiratory failure. The presence of all 3 factors resulted in a 57.1% mortality rate; in the absence of all 3, the mortality rate was 0%.^[6] Sailhamer concluded that despite awareness and treatment of fulminant C difficile colitis, this condition remains highly lethal. Thus, reliable predictors of mortality should be used to prompt aggressive surgical intervention.^[6] To determine the long-term survival rate, rate of gastrointestinal continuity restoration, and rate of recurrence following an attack of fulminant C difficile colitis, Miller et al searched a pathological database for patients with this condition, defined as those who had a bout of C difficile colitis and whose disease required surgical intervention after failing medical therapy.^[7] Of 49 patients who fit the criteria, the investigators found a 30-day mortality rate of 57% (28/49), with an in-hospital mortality rate of 49%. However, the 5-year survival rate for the long-term survival group was poor (38%) (16.3% for all patients). Twenty percent of patients had restored gastrointestinal continuity. One case of recurrence C difficile colitis was reported.
• Toxic megacolon is diagnosed clinically in a patient with signs and symptoms of severe toxicity, the presence of a tender abdomen, and a dilated colon on plain radiograph of the abdomen.
• Colonic perforation is usually accompanied by abdominal rigidity, involuntary guarding, rebound tenderness, and absent bowel sounds. Free air may be revealed on abdominal radiographs. Any suspicion of perforation in this setting should prompt immediate surgical consultation.

• Most patients with C difficile colitis recover, even without specific therapy. However, persistent diarrhea may be debilitating and can last for several weeks.
• By using oral metronidazole or vancomycin, response rates greater than 95% are obtained, with symptomatic improvement in as little as 2-3 days and complete resolution in 7-10 days.
• Approximately 20-27% of patients treated for a first episode of C difficile colitis relapse following successful therapy. Relapse is manifested by return of symptoms, usually occurring within a week of completing treatment.
• Patients who relapse once are at an even greater risk of further relapses. The relapse rate for those with 2 or more relapses is 65%.