Clostridium Difficile

Laura W. Lamps, MD

Key Facts

Terminology

Infection by Clostridium difficile, most common nosocomial GI infection
Causes colitis, most often pseudomembranous colitis

Etiology/Pathogenesis

Usually associated with recent antibiotic use, most commonly oral antibiotics
Elderly, debilitated, hospitalized patients also at increased risk

Clinical Issues

Typical symptoms
- Diarrhea, initially watery but variably bloody
- Fever
- Leukocytosis
- Abdominal pain
Recurrence common despite successful therapy
Patients with fulminant disease may have signs of acute abdomen but lack diarrhea
Incidence of severe or life-threatening infection is increasing

Macroscopic Features

Yellow-white exudates or pseudomembranes
Distribution: Entire colon or segmental/patchy

Microscopic Pathology

Ballooned or dilated glands
Intercrypt necrosis
Degenerating surface or glandular epithelial cells
Pseudomembranous exudate

Endoscopic photograph shows characteristic pseudomembranes in a C. difficile infection. (Courtesy W. Webb, MD.)

Hematoxylin & eosin illustrates a low-power view of pseudomembranous colitis, showing dilated crypts that give rise to a laminated, volcano-like, mucopurulent exudate.

TERMINOLOGY

Abbreviations

Clostridium difficile (C. difficile)

Synonyms

Pseudomembranous colitis

Definitions

Infection by Clostridium difficile, potent toxigenic bacteria
- Produces 2 toxins: Toxin A and toxin B
- Causes colitis, most often pseudomembranous colitis

ETIOLOGY/PATHOGENESIS

Recent Prior Antibiotic Exposure

Usually orally administered antibiotics
Bacteria cannot infect in presence of normal gut flora
Most common nosocomial GI pathogen

Other Risk Factors

Elderly patients
Severe comorbid illness/admission to ICU
- Inflammatory bowel disease
Indwelling nasogastric tubes
GI procedures
Antacids
Long hospitalization

CLINICAL ISSUES

Presentation

Diarrhea
- Ranging from mild to severe
- Initially watery
- Variably bloody
Fever
Leukocytosis
Abdominal pain
Symptoms can occur weeks after stopping antibiotics
Complications
- Toxic megacolon
- Perforation
- Reactive polyarthritis
Variant presentations
- May be superimposed on IBD
- Rare patients are asymptomatic
- Patients with fulminant disease may have signs of acute abdomen but lack diarrhea