Patient Encounter

A 70-year-old man presents to the ED because of diffuse abdominal pain and non-bloody diarrhea. One day earlier he had been discharged from the hospital, where he had received ceftriaxone and levofloxacin for 7 days for an upper respiratory infection. Soon after going home, he passed numerous liquid brown stools. A few hours later, the patient became disoriented, and an ambulance was called. His medical his-

tory is unremarkable. Laboratory values: WBC count 50 x 10 /mm (50 x 10 /L)/ mm3, hematocrit 43%, sodium 125 mEq/L (125 mmol/L), potassium 5.6 mEq/L (5.6 mmol/L), CO2 14 mEq/L (14 mmol/L), and metabolic acidosis. An abdominal radiograph series show no evidence of obstruction. The patient was admitted to the hospital.

What GI disease do you suspect based on this information? From your suspicion, what diagnostic tests and treatment would you recommend for this patient?

In the hospital, he receives fluids and vancomycin 125 mg orally four times daily. Stool was sent for C. difficile toxin assay, which came back positive. The patient continues to have abdominal pain but no bowel movement. On day 3 of hospitalization, his abdomen is distended with diffuse pain. His WBC count remains elevated. A CT scan of the abdomen showed colonic dilation to greater than 6 cm. The patient became febrile and hypotensive, requiring multiple pharmacologic support for hypotension.

What are this patient's risk factors for Clostridium difficile-associated diarrhea (CDAD)?

What do these new findings suggest?

How does this progression change your treatment recommendations?

In circumstances where oral therapy cannot be given, intravenous metronidazole (500 mg every 6-8 hours in adults), vancomycin retention enemas (500 mg every 4-8 hours in adults), or vancomycin via colonic catheter should be considered. 4 Antiperistaltic agents should not be given because the use of these agents is associated with the development of toxic megacolon.

Therapeutic response should be based on clinical signs and symptoms. A repeat toxin assay as a "test of cure" is not recommended because some patients may remain colonized with this organism following recovery. Treatment of asymptomatic colonized patients is not recommended as an infection-control measurement.

Relapse is suggested by the returning of symptoms 3 to 21 days after stopping met-ronidazole or vancomycin. Since antibiotic resistance is not a factor in relapse, most relapses usually respond to another course of either metronidazole or vancomycin. Currently, metronidazole is recommended for treatment of the first recurrence, while vancomycin pulse dosing (125 mg orally every 3 days for 3 weeks) or tapered dosing (125 mg orally four times daily for 10-14 days, then 125 mg orally twice daily for 7 days, then 125 mg orally daily for 7 days) is recommended for treatment of subsequent recurrences.

Vigilant hand washing and isolation precautions are keys to controlling C. difficile. Use of antimicrobial hand gel instead of soap and water is not a recommended alternative for patients infected with C. difficile.

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