Clostridium difficile colitis associated with treatment of Helicobacter pylori infection

Helicobacter pylori infection of the stomach is being detected and treated more often now than ever before. This is likely to result in an increase in complications such as antibiotic-associated diarrhea. However, there is no literature on the incidence of such diarrhea, particularly Clostridium difficile colitis, in patients treated for Helicobacter pylori infection. We report the case of a patient who developed Clostridium difficile colitis after treatment for Helicobacter pylori infection with metronidazole, amoxicillin, H2 blockers, and bismuth subsalicylate. This patient presented with severe diarrhea that responded to a course of metronidazole with rapid disappearance of symptoms. The incidence of Clostridium difficile colitis in patients treated for Helicobacter pylori infection has not been studied. This unique association, although not unexpected, has not yet been reported in the literature. The increasing number of patients being diagnosed and treated for this infection requires a heightened awareness on the part of physicians, to assure early diagnosis and treatment of this treatable, yet potentially dangerous, complication.     

Clostridium difficile and older adults: what primary care providers should know

Clostridium difficile poses particular risk for older adults, who are subject to more serious symptoms than younger patients. Antibiotic exposure and other risk factors are associated with the pathogenesis of C. difficile-associated disease. Treatment goals include prescribing anti-C. difficile activity agents (when indicated), attending to volume status and prescribing oral rehydration therapy as needed, avoiding the use of antiperistaltic drugs, discontinuing any offending antibiotics, avoiding the indiscriminate use of broad-spectrum antibiotics, providing supportive therapy, following infection control protocols, and eliminating environmental contaminants.     

Review article: antibiotic-induced Clostridium difficile infection

The great majority of cases of Clostridium difficile infection are hospital-acquired, and the reported incidence in England and Wales has increased sixfold between 1990 and 1993, with at least 17 patients dying in a recent large nosocomial outbreak. C. difficile infection accounts for an average 3-week increased length of stay in hospital. Acquisition of a toxigenic strain of Clostridium difficile may be followed by asymptomatic carriage, diarrhoea, colitis or pseudomembranous colitis. Antibiotic treatment and older age are major risk factors for the development of symptomatic disease, but less well-defined differences in strain virulence and host susceptibility are also probably important. Accurate data on the relative risks of different antibiotics to induce symptomatic C. difficile infection are scarce, but third-generation cephalosporins are frequently implicated. New kits are becoming available for the laboratory diagnosis of C. difficile infection but many of these lack sensitivity. Oral metronidazole or vancomycin are the main treatment options but avoidance of further antibiotics should also be encouraged where possible. The role of environmental C. difficile spores, which are highly resistant to conventional disinfectants, needs to be defined. Proven strategies for the prevention of C. difficile infection are required, in particular protocols to ensure that cross-infection does not occur.     

Fibronectin and laminin binding of eighteen Clostridium species

The ability of Clostridium difficile, Clostridium perfringens, Clostridium sporogenes and fifteen other Clostridium species to bind to human serum fibronectin or laminin was tested by using protein-coated latex particles. Three groups of Clostridium species were formed, namely the pseudomembranous colitis-causing species Clostridium difficile, the gas gangrene-causing Clostridium species and other Clostridium species, which are infrequently found in human infections. Significantly more strains of gas gangrene-causing Clostridium species, and strains of Clostridium species other than Clostridium difficile recognized fibronectin or laminin than did Clostridium difficile. Experiments with monoclonal antibodies revealed the specificity of the bacterial binding to fibronectin or laminin.     

Association of Clostridium difficile with enterocolitis and lactose intolerance in a foal

Diagnoses of Clostridium difficile enterocolitis and lactose intolerance were made in a neonatal foal with persistent diarrhea. It was determined that the foal had lactose intolerance on the basis of the results of a lactose tolerance test, and a diagnosis of C difficile enterocolitis was subsequently made. The foal responded to oral administration of metronidazole and lactase. Lactose intolerance is a secondary problem most commonly associated with rotavirus infection, but it can be caused by any condition affecting the small intestine. Because C difficile can affect the small intestine in foals, it was presumably the cause of the lactose intolerance in this foal with persistent diarrhea. Oral administration of lactase was not initially successful in this foal, most likely because of ongoing C difficile enterocolitis. Presumably, metronidazole was an effective treatment for C difficile enterocolitis and administration of lactase allowed for normal digestion of milk until endogenous lactose production returned. Clostridium difficile enterocolitis and lactose intolerance should be considered as differential diagnoses in neonatal foals with diarrhea, especially when the foal is bright and alert.     

Some aspects of the Clostridium difficile infection

Clostridium difficile is now regarded as the most common nosocomial enteric pathogen. C. difficile infection has a wide spectrum of a clinical presentation ranging from asymptomatic carriage to the fulminant colitis. Antibiotic therapy is the most important risk factor in pathogen contagion, however other factors are also involved. Typical pathophysiology: 1. alteration of the indigenous colonic flora by antibodies, 2. ingestion of spores, 3. colonization by Clostridium difficile, 4. production of its toxins. Both entherotoxin A and cytotoxin B are active in human colon. The mode of action of these toxins is already quite well known. The main treatment includes withdrawal of the inducing agents, supported occasionally by oral Vancomycin and Metronidazole. Relapse is a major complication.     

Fluoride treatment for facial nerve stimulation caused by cochlear implants in otosclerosis

Clostridium difficile (C. difficile) pseudomembraneous colitis was diagnosed in a 13-year-old boy with Hodgkin's disease 3 months after autologous bone marrow transplantation. Hematopoiesis was fully reconstituted at the time. C. difficile infection occurred after gall bladder empyema had been treated conservatively with i.v. antibiotics and prophylactic 4-week administration of oral amoxicillin. C. difficile colitis was diagnosed early and intensive supportive therapy combined with administration of i.v. and subsequently oral vancomycin therapy failed. It is a phenomenon rarely seen and successful eradication of the clostridium infection was only achieved by a combination of higher dose vancomycin with metronidazole. During the post-colitis recovery the patient experienced a relapse of Hodgkin's disease and died following further surgical intervention 137 days post-transplantation.     

Diurnal and weekly variation of tardive dyskinesia measured by digital image processing

The causes and clinical manifestations of Clostridium difficile infection in children are described in this report. The studies were performed on three children aged up to 3 years. Risk factors as well as possible diagnostic and therapeutic procedures are discussed.     

Polyarthritis with perinuclear antineutrophil cytoplasmic antibody inaugurating microscopic polyangiitis. Report of a case

The prevalence of, and clinical risk factors associated with, vancomycin-resistant enterococcal colonization were investigated in patients suspected of having Clostridium difficile infection. Stools submitted for C difficile cytotoxin testing were screened for vancomycin-resistant enterococci (VRE). Isolates were speciated and characterized further by antibiotic susceptibility testing, DNA fingerprinting, and DNA:DNA hybridization for detection of specific vancomycin resistance genes. Of the 79 evaluable patients identified during a 3-month period, 16.5% were VRE-positive. The VRE isolates were genetically heterogeneous, although all carried the vanA gene. DNA fingerprinting data suggest that patient-to-patient transmission occurred, implicating colonized patients as potential reservoirs for VRE transmission. A positive C difficile cytotoxin assay and diabetes mellitus were the only identifiable risk factors associated with VRE colonization. Patients at risk for C difficile infection therefore may serve as reservoirs for VRE.     

Infection due to Clostridium difficile among elderly residents of a long-term-care facility

In a study of the epidemiology of infection due to Clostridium difficile at long-term-care facilities, we conducted point-prevalence surveys and obtained stool samples from residents receiving antibiotics and from those developing diarrhea during 1 year at a 350-bed nursing home and an adjoining 280-bed chronic-care hospital. C. difficile and/or its cytotoxin was detected in 236 specimens from 94 residents. Only 16 (17%) of these 94 individuals had diarrhea at the time C. difficile was detected. The prevalence of C. difficile infection ranged from 2.1% to 8.1% in the nursing home and from 7.1% to 14.7% in the hospital. The organism was recovered from six (8.8%) of 68 residents receiving antibiotics, and four of the six developed antibiotic-associated diarrhea. The receipt of antibiotic treatment within the previous 8 weeks (odds ratio [OR], 7.9), the presence of a nasogastric or gastrostomy feeding tube (OR, 6.5), urinary and fecal incontinence (OR, 2.5), and the presence of more than three underlying diseases (OR, 2.0) were statistically significant independent variables associated with C. difficile infection. Typing of isolates by restriction-endonuclease analysis indicated that most C. difficile infections at this long-term-care facility were associated with endogenous enteric carriage of the organism, with little evidence of cross-infection.     

Severe Clostridium difficile-associated colitis in young patients with cystic fibrosis

We report four patients with cystic fibrosis and fulminant Clostridium difficile-associated colitis: two died, and one required hemicolectomy. Three of four patients carried the N1303K mutation. Severe and fatal C. difficile colitis can occur in cystic fibrosis patients, possibly with a genotype-specific predilection (i.e., N1303K/other). Because cystic fibrosis patients may have a wide spectrum of gastrointestinal symptoms, disease caused by C. difficile must be considered when these patients have acute abdominal pain, diarrhea, or severe leukocytosis.     

Lipid metabolism in pregnancy. VIII. Effects of dietary fat versus carbohydrate on lipoprotein and hepatic lipids and tissue triglyceride lipases

From 1324 patients with antibiotic-associated diarrhea (AAD) 1643 stool samples were analyzed by a cell test for Clostridium difficile toxin in stool filtrates and cultivation for occurrence of C. difficile strains. In patients with no detectable toxin in their stool strains of C. difficile were isolated in 2.2% whereas when toxin was detectable, the isolation rate varied from 17% to 36%. Furthermore, there was a correlation between toxin titre in stool filtrate and production of cytotoxin in vitro by the corresponding C. difficile strains. Five clostridial strains, not belonging to the species C. difficile, were found to produce typical cytotoxin in vitro. However, five strains identified as C. difficile by biochemical reactions and gas liquid chromatography, did not produce an extracellular cytotoxin. The antibiotic susceptibility patterns of the Clostridium strains were investigated. No correlation was recognized between antibiotic resistance of isolated Clostridium strains and the AAD-inducing antibiotic penicillins and linco/clindamycin. Neither did cases of relapse of diarrheal disease after vancomycin treatment harbour C. difficile strains with increased resistance to vancomycin. It is concluded that the pathogenesis of antibiotic-associated enterocolitis is more complex than a mere intestinal overgrowth of resistant strains of C. difficile.     

Progresses in the study of microcirculation in China, 1997

Splenic abscess is a previously unreported complication of Clostridium difficile colitis. A case of Clostridium difficile splenic abscess is reported that developed after the patient had been in intensive care for five weeks. A response was seen to radiologically guided drainage and antibiotic therapy with formal laparotomy, and surgical drainage not being required.     

Atypical presentation of Clostridium difficile colitis in patients with cystic fibrosis

OBJECTIVE: This report describes the unusual presentation of Clostridium difficile colitis in five patients with cystic fibrosis and the role of CT in first suggesting the correct diagnosis in this group of patients. Because of the absence of watery diarrhea and the presence of abdominal bloating and decreased stooling, cystic fibrosis patients with C. difficile colitis will be treated for stool impaction, meconium ileus equivalent, or distal intestinal obstruction syndrome. CT of the abdomen, performed in these five patients because of their lack of improvement after standard therapy for stool impaction, showed an extensive pancolitis later confirmed to be caused by C. difficile infection. CONCLUSION: In patients with cystic fibrosis, imaging findings of a pancolitis should raise the possibility of C. difficile colitis despite the lack of watery diarrhea. Anticlostridial treatment can be initiated before bacteriologic confirmation is obtained.     

Prospective study of the risk of Clostridium difficile diarrhoea in elderly patients following treatment with cefotaxime or piperacillin-tazobactam

BACKGROUND: Rates of Clostridium difficile diarrhoea have recently been rising, with the elderly being at highest risk. AIM: To compare the incidence of C. difficile colonization and diarrhoea in elderly patients treated for presumed infection with either empirical cefotaxime (CTX) or piperacillin-tazobactam (PT). METHODS: A prospective, ward-based, crossover study was carried out on two well-matched care of the elderly wards at a UK tertiary care hospital, in patients requiring empirical broad-spectrum antibiotic treatment. RESULTS: There was a highly significant increased incidence of C. difficile colonization (26/34 vs. 3/14, P=0.001) and diarrhoea (18/34 vs. 1/14, P=0.006) in patients who received CTX as opposed to PT. DNA fingerprinting suggested that most infections arose from strains acquired from the hospital environment. CONCLUSIONS: Elderly patients are significantly less likely to develop C. difficile diarrhoea after treatment with PT than after CTX. The source of C. difficile appears to be predominantly from the ward environment.     

Hospital-acquired infection in elderly patients

Increasing numbers of elderly people are being treated in hospitals and are at particular risk of acquiring infections. The incidence, risk factors and types of hospital-acquired infection (HAI) in the elderly are reviewed. Special reference is made to urinary tract infections, respiratory tract infections, gastrointestinal infections including Clostridium difficile, bacteraemia, skin and soft tissue infections and infections with antibiotic-resistant organisms.     

Clostridium difficile infection is a risk factor for bacteremia due to vancomycin-resistant enterococci (VRE) in VRE-colonized patients with acute leukemia

A cohort study was conducted in a cancer center to identify risk factors for bacteremia with vancomycin-resistant enterococci (VRE) in neutropenic cancer patients colonized with VRE. There were 10 patients with VRE bacteremia among 56 colonized with VRE, of whose charts 51 were available for review. One hundred percent of patients with VRE bacteremia (10 of 10) vs. 56% of patients without VRE bacteremia (23 of 41) had acute leukemia (P = .01, Fisher's exact test). Four of the 10 patients with VRE bacteremia had a positive Clostridium difficile toxin assay within 6 days of their first positive VRE blood culture. Both C. difficile infection and antimicrobial (vancomycin and ciprofloxacin) use during VRE colonization were significant risk factors for VRE bacteremia in univariate analysis. When a Cox proportional hazards model was used to account for differences in follow-up time, C. difficile infection was the only statistically significant risk factor (risk ratio, 8.2; P = .007) for VRE bacteremia in VRE-colonized patients with acute leukemia.     

Review article: the use of biotherapeutic agents in the prevention and treatment of gastrointestinal disease

There is presently a lack of well conducted clinical trials demonstrating any significant benefits of probiotics in humans. With the exception of diarrhoea due to rotavirus infection in children there is little evidence from randomized, double-blind, placebo-controlled studies that bacterial probiotics have a significant beneficial action in preventing diarrhoea of any cause. The yeast Saccharomyces boulardii has been shown to be of benefit in the prevention of antibiotic-associated diarrhoea but not in preventing infection with Clostridium difficile. S. boulardii may also be of benefit in preventing relapse of C. difficile infection. Because of the simplicity of in vitro systems and some animal models, beneficial characteristics of probiotics such as the ability of bacteria to bind to epithelial surfaces are not always transferable to humans. Thus any postulated benefit from consumption of probiotic bacteria should only be accepted as fact after testing in clinical studies. This review outlines our present knowledge of the mode of action of probiotics and presents the data from clinical trials on their use.     

Weight loss in the clinical setting: applications for cardiac rehabilitation

A 57-year-old man developed oligoarthritis of the right sacroiliac joint, knee and elbow in the wake of Clostridium difficile pseudomembranous colitis. He was HLA B27-positive and had a history of Reiter's syndrome. His joint manifestations resolved after a course of nonsteroidal antiinflammatory drug therapy and injection of the right knee with triamcinolone acetonide. Clostridium difficile should be recognized as a rare cause of reactive arthritis.     

Single toxin detection is inadequate to diagnose Clostridium difficile diarrhea in pediatric patients

BACKGROUND & AIMS: Clostridium difficile is an important cause of symptomatic diarrhea in pediatric patients. The bacterium produces two toxins, although many laboratories assay for only one. We questioned this diagnostic approach when patients had positive results for C. difficile at our institution, but initially had tested negative at outside laboratories. METHODS: We retrospectively analyzed relative frequencies of C. difficile toxin A alone, toxin B alone, and toxins A and B from pediatric patients with diarrhea. Results were stratified according to toxin detection and patient age. RESULTS: Of 1061 specimens, 276 (26.8%) were positive for C. difficile toxin(s). Fifty-one (18.5%) were positive for toxin A alone, 133 (48.2%) for toxin B alone, and 92 (33.3%) for both toxins. Assaying for toxin B identified C. difficile infection more frequently than did assaying for toxin A (P < 0.0001). The frequency of toxin B detection was significantly higher for older children but not for infants. CONCLUSIONS: Testing for C. difficile toxin A or toxin B alone will result in more frequent misdiagnosis than testing for both toxins. This practice may lead to inappropriate further invasive investigations in children, although this finding may not be applicable to adults.