Pseudomembranous Colitis Follow-up

  • Author: Jennifer A Curry, MD, MPH; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Sep 6, 2011
 

Further Inpatient Care

  • Further inpatient care is required only if the patient continues to have significant diarrhea, related fluid losses, or other medical issues; otherwise, outpatient therapy may be appropriate
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Further Outpatient Care

  • Follow-up care is not generally required.
  • The return of diarrhea may indicate the need for retreatment for recurrent disease.
  • After treatment, repeat C difficile testing is not recommended if the patient’s symptoms have resolved, as patients may remain colonized.
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Inpatient & Outpatient Medications

  • Optimal treatments are discussed in Treatment and include antibiotics with activity against C difficile.
  • The use of antidiarrheals such as loperamide is not recommended in the treatment of acute C difficile –associated diarrhea.
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Deterrence/Prevention

  • Proper stewardship of antibiotics may limit the risk of CDI.
  • Avoidance of unnecessary antibiotics, especially within the first few months after treatment for CDI, may limit the risk of recurrent disease.
  • Implementation of infection control procedures is imperative to control spread.
    • C difficile is shed in feces. Any surface or material that becomes contaminated with feces may serve as a reservoir for the C difficile spores.
    • Use contact isolation for infected patients, particularly those with bowel incontinence. Infected patients can be isolated in private rooms (preferred) or through cohorting of patients with C difficile infection.
      • In patients with severe diarrhea causing fecal incontinence and suspected C difficile, some advocate initiation of contact isolation while confirmatory testing is pending.
      • Contact isolation can be terminated when the diarrhea has resolved.
      • Discontinuation of contact precautions does not require negative C difficile testing.
      • Gloves and gowns should be used during all patient contact.
    • Dedicate equipment when possible.
    • Hands should be washed with soap and water. Alcohol-based hand solutions may not be as effective against spore-forming bacteria.
    • Hospital rooms must be appropriately cleaned to ensure sterilization of spores. Hypochlorite-based disinfectants (eg, chlorine bleach) have been used with some success.
  • Probiotics are not currently recommended for the primary prevention of C difficile infection. Probiotics have shown efficacy in reducing the incidence of simple antibiotic-associated diarrhea, but their efficacy in preventing C difficile infection is inconsistent. Studies to date on probiotics have generally been nonrandomized, small in size, and/or have used highly selected patient populations.
    • Saccharomyces boulardii yeast
      • S boulardii rapidly colonizes the bowel without significantly altering the remaining bowel flora, and it is cleared from the bowel after cessation of therapy.
      • Safety concerns exist regarding fungemia with use in immunocompromised patients.
      • It is available as the dietary supplement Florastor in the United States.
    • Lactobacillus
      • Lactobacillus is available as a "natural" product with limited quality control.
      • In 2004, a small randomized controlled trial showed a 50% reduction in the incidence of CDI when used as prophylaxis initiated at the time of antibiotic therapy.[51] Later studies have not shown a similar effect, potentially due to variations in the product used.
    • Bio-K+ CL1285
      • Bio-K+ is newer pharmaceutical grade product containing Lactobacillus acidophilus and Lactobacillus casei.
      • In a randomized, double-blind placebo trial of 255 hospitalized patients aged 50-70 receiving penicillin, cephalosporin, or clindamycin, use of this probiotic was associated with a reduction in the rates of CDI by over half.[52] This trial was one of the most stringent to date to evaluate use of a probiotic, but it targets a very narrow patient population.
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Complications

  • Major complications of acute disease include development of toxic megacolon, transverse volvulus, or colon perforation. These complications can be avoided with early detection and treatment, avoidance of antimotility agents in patients with nosocomial diarrhea (until etiology is known), and early surgical consultation.
  • Recurrent colitis and diarrhea occur in approximately 25% of patients (depending on populations studied), typically 2 weeks to 2 months after successful therapy completion. Occasionally, numerous (>6) episodes may occur. The etiology is unclear; however, the persistence of spores is thought to be related. Recurrent colitis usually does not represent the development of resistant organisms.
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Prognosis

  • When properly treated, CDI is a limited disease process with a good prognosis; however, recurrent disease is not unusual.
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Patient Education

  • Education is critical for health care providers and should include proper contact isolation procedures for infected patients (ie, use of gloves, hand washing, disposable thermometers).
  • Patient education should include instruction about the link of the disease with antibiotic use and the need to return for retreatment if symptoms return.
  • Patient education regarding the adverse effects of metronidazole, including metallic taste and adverse reaction to alcohol-containing fluids, should be provided.
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Contributor Information and Disclosures
Author

Jennifer A Curry, MD, MPH  Attending Physician, Infectious Disease Clinic, Naval Medical Center Portsmouth; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences

Jennifer A Curry, MD, MPH is a member of the following medical societies: American College of Physicians, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Gary L Gorby, MD  Associate Professor, Departments of Internal Medicine and Medical Microbiology and Immunology, Division of Infectious Diseases, Creighton University School of Medicine; Associate Professor of Medicine, University of Nebraska Medical Center; Associate Chair, Omaha Veterans Affairs Medical Center

Gary L Gorby, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and New York Academy of Sciences

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Joseph F John Jr, MD, FACP, FIDSA, FSHEA  Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Acknowledgments

The views expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. government.

LCDR Jennifer Curry is a military service member. This work was prepared as part of official duties. Title 17 U.S.C. §105 provides that ‘Copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C. §101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties.

Many thanks to Duane R Hospenthal, MD, PhD, Joseph Lee, MD, and Braden Hale, MD, MPH for their work on earlier versions of this topic.

References

  1. Bartlett JG. Clinical practice. Antibiotic-associated diarrhea. N Engl J Med. Jan 31 2002;346(5):334-9. [Medline].

  2. Loo VG, Poirier L, Miller MA, et al. A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrhea with high morbidity and mortality. N Engl J Med. Dec 8 2005;353(23):2442-9. [Medline].

  3. McDonald LC, Killgore GE, Thompson A, et al. An epidemic, toxin gene-variant strain of Clostridium difficile. N Engl J Med. Dec 8 2005;353(23):2433-41. [Medline].

  4. Stabler RA, Gerding DN, Songer JG, et al. Comparative phylogenomics of Clostridium difficile reveals clade specificity and microevolution of hypervirulent strains. J Bacteriol. Oct 2006;188(20):7297-305. [Medline]. [Full Text].

  5. Belmares J, Johnson S, Parada JP, et al. Molecular epidemiology of Clostridium difficile over the course of 10 years in a tertiary care hospital. Clin Infect Dis. Oct 15 2009;49(8):1141-7. [Medline].

  6. Dubberke ER. The A, B, BI, and Cs of Clostridium difficile. Clin Infect Dis. Oct 15 2009;49(8):1148-52. [Medline].

  7. Cohen SH, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the society for healthcare epidemiology of America (SHEA) and the infectious diseases society of America (IDSA). Infect Control Hosp Epidemiol. May 2010;31(5):431-55. [Medline].

  8. Samore MH, DeGirolami PC, Tlucko A, Lichtenberg DA, Melvin ZA, Karchmer AW. Clostridium difficile colonization and diarrhea at a tertiary care hospital. Clin Infect Dis. Feb 1994;18(2):181-7. [Medline].

  9. McFarland LV, Surawicz CM, Greenberg RN, Bowen KE, Melcher SA, Mulligan ME. Possible role of cross-transmission between neonates and mothers with recurrent Clostridium difficile infections. Am J Infect Control. Jun 1999;27(3):301-3. [Medline].

  10. McDonald LC, Owings M, Jernigan DB. Clostridium difficile infection in patients discharged from US short-stay hospitals, 1996-2003. Emerg Infect Dis. Mar 2006;12(3):409-15. [Medline].

  11. Miller AB. Fifth Decennial International Conference on Healthcare-Associated Infections (ICHAI) 2010: Abstract 386, presented March 20, 2010.

  12. Gravel D, Miller M, Simor A, Taylor G, Gardam M, McGeer A. Health care-associated Clostridium difficile infection in adults admitted to acute care hospitals in Canada: a Canadian Nosocomial Infection Surveillance Program Study. Clin Infect Dis. Mar 1 2009;48(5):568-76. [Medline].

  13. Miller MA, Hyland M, Ofner-Agostini M, Gourdeau M, Ishak M. Morbidity, mortality, and healthcare burden of nosocomial Clostridium difficile-associated diarrhea in Canadian hospitals. Infect Control Hosp Epidemiol. Mar 2002;23(3):137-40. [Medline].

  14. Kyne L, Hamel MB, Polavaram R, Kelly CP. Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile. Clin Infect Dis. Feb 1 2002;34(3):346-53. [Medline].

  15. Miller M, Gravel D, Mulvey M, et al. Health care-associated Clostridium difficile infection in Canada: patient age and infecting strain type are highly predictive of severe outcome and mortality. Clin Infect Dis. Jan 15 2010;50(2):194-201. [Medline].

  16. Kim J, Smathers SA, Prasad P, Leckerman KH, Coffin S, Zaoutis T. Epidemiological features of Clostridium difficile-associated disease among inpatients at children's hospitals in the United States, 2001-2006. Pediatrics. Dec 2008;122(6):1266-70. [Medline].

  17. McFarland LV. Renewed interest in a difficult disease: Clostridium difficile infections--epidemiology and current treatment strategies. Curr Opin Gastroenterol. Jan 2009;25(1):24-35. [Medline].

  18. Sanchez TH, Brooks JT, Sullivan PS, et al. Bacterial diarrhea in persons with HIV infection, United States, 1992-2002. Clin Infect Dis. Dec 1 2005;41(11):1621-7. [Medline].

  19. Kyne L, Merry C, O'Connell B, Kelly A, Keane C, O'Neill D. Factors associated with prolonged symptoms and severe disease due to Clostridium difficile. Age Ageing. Mar 1999;28(2):107-13. [Medline].

  20. Peterson LR, Robicsek A. Does my patient have Clostridium difficile infection?. Ann Intern Med. Aug 4 2009;151(3):176-9. [Medline].

  21. Cardona DM, Rand KH. Evaluation of repeat Clostridium difficile enzyme immunoassay testing. J Clin Microbiol. Nov 2008;46(11):3686-9. [Medline]. [Full Text].

  22. Nemat H, Khan R, Ashraf MS, et al. Diagnostic value of repeated enzyme immunoassays in Clostridium difficile infection. Am J Gastroenterol. Aug 2009;104(8):2035-41. [Medline].

  23. Valiquette L, Pepin J, Do XV, et al. Prediction of complicated Clostridium difficile infection by pleural effusion and increased wall thickness on computed tomography. Clin Infect Dis. Aug 15 2009;49(4):554-60. [Medline].

  24. Zar FA, Bakkanagari SR, Moorthi KM, Davis MB. A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Clin Infect Dis. Aug 1 2007;45(3):302-7. [Medline].

  25. Noblett SE, Welfare M, Seymour K. The role of surgery in Clostridium difficile colitis. BMJ. May 6 2009;338:b1563. [Medline].

  26. Neal MD, Alverdy JC, Hall DE, Simmons RL, Zuckerbraun BS. Diverting Loop Ileostomy and Colonic Lavage: An Alternative to Total Abdominal Colectomy for the Treatment of Severe, Complicated Clostridium difficile Associated Disease. Ann Surg. Sep 2011;254(3):423-9. [Medline].

  27. Johnson S, Sanchez JL, Gerding DN. Metronidazole resistance in Clostridium difficile. Clin Infect Dis. Aug 2000;31(2):625-6. [Medline].

  28. Bolton RP, Culshaw MA. Faecal metronidazole concentrations during oral and intravenous therapy for antibiotic associated colitis due to Clostridium difficile. Gut. Oct 1986;27(10):1169-72. [Medline]. [Full Text].

  29. Antibiotic treatment for Clostridium difficile-associated diarrhea in adults [database online]. Cochrane Database Syst Rev; 2005 Jan 25.

  30. Aslam S, Musher DM. An update on diagnosis, treatment, and prevention of Clostridium difficile-associated disease. Gastroenterol Clin North Am. Jun 2006;35(2):315-35. [Medline].

  31. Surowiec D, Kuyumjian AG, Wynd MA, Cicogna CE. Past, present, and future therapies for Clostridium difficile-associated disease. Ann Pharmacother. Dec 2006;40(12):2155-63. [Medline].

  32. de Lalla F, Privitera G, Rinaldi E, Ortisi G, Santoro D, Rizzardini G. Treatment of Clostridium difficile-associated disease with teicoplanin. Antimicrob Agents Chemother. Jul 1989;33(7):1125-7. [Medline].

  33. Wenisch C, Parschalk B, Hasenhundl M, Hirschl AM, Graninger W. Comparison of vancomycin, teicoplanin, metronidazole, and fusidic acid for the treatment of Clostridium difficile-associated diarrhea. Clin Infect Dis. May 1996;22(5):813-8. [Medline].

  34. Musher DM, Logan N, Hamill RJ, et al. Nitazoxanide for the treatment of Clostridium difficile colitis. Clin Infect Dis. Aug 15 2006;43(4):421-7. [Medline].

  35. Johnson S, Schriever C, Galang M, Kelly CP, Gerding DN. Interruption of recurrent Clostridium difficile-associated diarrhea episodes by serial therapy with vancomycin and rifaximin. Clin Infect Dis. Mar 15 2007;44(6):846-8. [Medline].

  36. Pullman J, Prieto J, Leach TS. Ramoplanin vs. Vancomycin in the treatment of Clostridium difficile diarrhea: A Phase 2 Study, poster presented at the 44th ICAAC, an annual meeting of the American Society for Microbiology, October 2004.

  37. Credito KL, Appelbaum PC. Activity of OPT-80, a novel macrocycle, compared with those of eight other agents against selected anaerobic species. Antimicrob Agents Chemother. Nov 2004;48(11):4430-4. [Medline]. [Full Text].

  38. Louie TJ, Peppe J, Watt CK, Johnson D, Mohammed R, Dow G. Tolevamer, a novel nonantibiotic polymer, compared with vancomycin in the treatment of mild to moderately severe Clostridium difficile-associated diarrhea. Clin Infect Dis. Aug 15 2006;43(4):411-20. [Medline].

  39. Kyne L, Warny M, Qamar A, Kelly CP. Association between antibody response to toxin A and protection against recurrent Clostridium difficile diarrhoea. Lancet. Jan 20 2001;357(9251):189-93. [Medline].

  40. Aboudola S, Kotloff KL, Kyne L, et al. Clostridium difficile vaccine and serum immunoglobulin G antibody response to toxin A. Infect Immun. Mar 2003;71(3):1608-10. [Medline]. [Full Text].

  41. Babcock GJ, Broering TJ, Hernandez HJ, Mandell RB, Donahue K, Boatright N. Human monoclonal antibodies directed against toxins A and B prevent Clostridium difficile-induced mortality in hamsters. Infect Immun. Nov 2006;74(11):6339-47. [Medline].

  42. Lowy I, Molrine DC, Leav BA, et al. Treatment with monoclonal antibodies against Clostridium difficile toxins. N Engl J Med. Jan 21 2010;362(3):197-205. [Medline].

  43. Fung HB, Doan TL. Tinidazole: a nitroimidazole antiprotozoal agent. Clin Ther. Dec 2005;27(12):1859-84. [Medline].

  44. Musher DM, Aslam S, Logan N, et al. Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis. Jun 1 2005;40(11):1586-90. [Medline].

  45. Pepin J, Alary ME, Valiquette L, et al. Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada. Clin Infect Dis. Jun 1 2005;40(11):1591-7. [Medline].

  46. Aslam S, Hamill RJ, Musher DM. Treatment of Clostridium difficile-associated disease: old therapies and new strategies. Lancet Infect Dis. Sep 2005;5(9):549-57. [Medline].

  47. McFarland LV, Elmer GW, Surawicz CM. Breaking the cycle: treatment strategies for 163 cases of recurrent Clostridium difficile disease. Am J Gastroenterol. Jul 2002;97(7):1769-75. [Medline].

  48. Aas J, Gessert CE, Bakken JS. Recurrent Clostridium difficile colitis: case series involving 18 patients treated with donor stool administered via a nasogastric tube. Clin Infect Dis. Mar 1 2003;36(5):580-5. [Medline].

  49. Wilcox MH. Descriptive study of intravenous immunoglobulin for the treatment of recurrent Clostridium difficile diarrhoea. J Antimicrob Chemother. May 2004;53(5):882-4. [Medline].

  50. McPherson S, Rees CJ, Ellis R, Soo S, Panter SJ. Intravenous immunoglobulin for the treatment of severe, refractory, and recurrent Clostridium difficile diarrhea. Dis Colon Rectum. May 2006;49(5):640-5. [Medline].

  51. Plummer S, Weaver MA, Harris JC, Dee P, Hunter J. Clostridium difficile pilot study: effects of probiotic supplementation on the incidence of C. difficile diarrhoea. Int Microbiol. Mar 2004;7(1):59-62. [Medline].

  52. Gao XW, Mubasher M, Fang CY, Reifer C, Miller LE. Dose-response efficacy of a proprietary probiotic formula of Lactobacillus acidophilus CL1285 and Lactobacillus casei LBC80R for antibiotic-associated diarrhea and Clostridium difficile-associated diarrhea prophylaxis in adult patients. Am J Gastroenterol. Jul 2010;105(7):1636-41. [Medline].

  53. Apisarnthanarak A, Razavi B, Mundy LM. Adjunctive intracolonic vancomycin for severe Clostridium difficile colitis: case series and review of the literature. Clin Infect Dis. Sep 15 2002;35(6):690-6. [Medline].

  54. Bartlett JG. Clinical practice. Antibiotic-associated diarrhea. N Engl J Med. Jan 31 2002;346(5):334-9. [Medline].

  55. Bartlett JG. Clostridium difficile: history of its role as an enteric pathogen and the current state of knowledge about the organism. Clin Infect Dis. May 1994;18 Suppl 4:S265-72. [Medline].

  56. Cotran RS, Kumar V, Robbins S. Robbins Pathologic Basis of Disease. WB Saunders Co; 1989:360-1.

  57. D'Souza AL, Rajkumar C, Cooke J, Bulpitt CJ. Probiotics in prevention of antibiotic associated diarrhoea: meta-analysis. BMJ. Jun 8 2002;324(7350):1361. [Medline]. [Full Text].

  58. [Guideline] Dubberke ER, Gerding DN, Classen D, et al. Strategies to prevent clostridium difficile infections in acute care hospitals. Infect Control Hosp Epidemiol. Oct 2008;29 Suppl 1:S81-92. [Medline].

  59. Fekety R. Guidelines for the diagnosis and management of Clostridium difficile-associated diarrhea and colitis. American College of Gastroenterology, Practice Parameters Committee. Am J Gastroenterol. May 1997;92(5):739-50. [Medline].

  60. Friedenberg F, Fernandez A, Kaul V, Niami P, Levine GM. Intravenous metronidazole for the treatment of Clostridium difficile colitis. Dis Colon Rectum. Aug 2001;44(8):1176-80. [Medline].

  61. Gerding DN, Johnson S, Peterson LR, Mulligan ME, Silva J Jr. Clostridium difficile-associated diarrhea and colitis. Infect Control Hosp Epidemiol. Aug 1995;16(8):459-77. [Medline].

  62. Jiang ZD, DuPont HL, Garey K, Price M, Graham G, Okhuysen P. A common polymorphism in the interleukin 8 gene promoter is associated with Clostridium difficile diarrhea. Am J Gastroenterol. May 2006;101(5):1112-6. [Medline].

  63. Jodlowski TZ, Oehler R, Kam LW, Melnychuk I. Emerging therapies in the treatment of Clostridium difficile-associated disease. Ann Pharmacother. Dec 2006;40(12):2164-9. [Medline].

  64. Johnson S, Gerding DN. Clostridium difficile--associated diarrhea. Clin Infect Dis. May 1998;26(5):1027-34; quiz 1035-6. [Medline].

  65. Johnson S, Homann SR, Bettin KM, et al. Treatment of asymptomatic Clostridium difficile carriers (fecal excretors) with vancomycin or metronidazole. A randomized, placebo-controlled trial. Ann Intern Med. Aug 15 1992;117(4):297-302. [Medline].

  66. Kelly CP, LaMont JT. Clostridium difficile--more difficult than ever. N Engl J Med. Oct 30 2008;359(18):1932-40. [Medline].

  67. Kelly CP, Pothoulakis C, LaMont JT. Clostridium difficile colitis. N Engl J Med. Jan 27 1994;330(4):257-62. [Medline].

  68. Kim J, Smathers SA, Prasad P, Leckerman KH, Coffin S, Zaoutis T. Epidemiological features of Clostridium difficile-associated disease among inpatients at children's hospitals in the United States, 2001-2006. Pediatrics. Dec 2008;122(6):1266-70. [Medline].

  69. Leffler DA, Lamont JT. Treatment of Clostridium difficile-associated disease. Gastroenterology. May 2009;136(6):1899-912. [Medline].

  70. Monaghan T, Boswell T, Mahida YR. Recent advances in Clostridium difficile-associated disease. Gut. Jun 2008;57(6):850-60. [Medline].

  71. Mylonakis E, Ryan ET, Calderwood SB. Clostridium difficile--Associated diarrhea: A review. Arch Intern Med. Feb 26 2001;161(4):525-33. [Medline].

  72. Noblett SE, Welfare M, Seymour K. The role of surgery in Clostridium difficile colitis. BMJ. May 6 2009;338:b1563. [Medline].

  73. O'Connor JR, Johnson S, Gerding DN. Clostridium difficile infection caused by the epidemic BI/NAP1/027 strain. Gastroenterology. May 2009;136(6):1913-24. [Medline].

  74. Pépin J, Saheb N, Coulombe MA, et al. Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec. Clin Infect Dis. Nov 1 2005;41(9):1254-60. [Medline].

  75. Theilman NM, Wilson KH. Antibiotic associated colitis. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 6th ed. Churchill Livingstone; 2005:1249-62.

 
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Colonic pseudomembranes of pseudomembranous colitis. Photographs courtesy of Eric M. Osgard, MD.
 
 
 
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