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CLOSTRIDIUM DIFFICILE INFECTION: NON DIARRHEAL PRESENTATION

"No bubble is so iridescent or floats longer than 
that blown by the successful teacher"
                                                      -William Osler

Clostridium difficile, a spore-forming gram-positive anaerobic bacillus, was initially detected in the fecal flora of healthy newborns in 1935. Clostridium difficile was thought to be nonpathogenic until 1978, when Bartlett et al identified C. difficile as the source of cytotoxin in the stools of patients with pseudomembranous colitis, a disorder frequently associ- ated with antimicrobial use.

Clostridium difficile infection (CDI) range from asymptomatic carrier, to mild diarrhea, to fulminant pseudomembranous colitis.

C. difficile associated diarrhea (CDAD) is the most common cause of infectious diarrhea in hospital setting. It accounts for 20-30% cases of antibiotic associated diarrhea. It is associated with passage of mucus or occult blood in stool, but melena or hematochezia are rare. Fever, cramping, abdominal discomfort, and a  peripheral  leukocytosis  are  common  but  found  in  fewer than  half  of  patients.

Case definition CDI should include presence of symptoms (usually diarrhea) and either a stool test result positive for C. difficile toxins or toxicogenic C. difficile or colonoscopy finding demonstrating pseudomembranous colitis.

Antimicrobial use is not included in clinical definition of CDI because of occasional case reports of CDI in the absence of antimicrobial use, usually in community acquired case.

Severity: CDI disease severity has be classified as mild to moderate, severe and complicated.

Mild to moderate disease is defined as CDI with diarrhea.
Severe disease is defined as CDI hypoalbuminemia (serum albumin 3 gm/dl) and WBC more than 15000 cells/cmm or abdominal tenderness.
Complicated disease is defined as severe CDI with any of the following: shock, temperature more than 38.5 C, ileus, WBC more than 35000 or less than 2000, serum lactate more than 2.2 mmol/l or evidence of organ failure.

Risk factors for CDI include antimicrobial use, advance age, duration of hospitalization, cancer chemotherapy, gastrointestinal surgery, manipulation of gastrointestinal tract, including tube feeding, and gastric acid neutralising agents. 

CDI is usually associated with diarrhea. However it can present without diarrhea, unexplained leukocytosis, abdominal distension, ileus or toxic megacolon and abdominal compartment syndrome.

Critically ill patients with severe CDI have multiple risk factors for development of gastrointestinal dysmotility, intraabdominal hypertension and abdominal compartment syndrome. These include shock, ischemia, electrolyte disturbances, massive fluid resuscitation, bowel wall edema causing ileus, colonic psedoobstruction and megacolon.

Incidence of intraabdominal hypertension in critically ill patients is about sixty percent.

Abnormal gastrointestinal motility is one of the cause as well association of intraabdominal hypertension in critically ill patients. It has mulitifactorial origin, resulting in frequent interruption in enteral feeding and ileus/ colonic pseudoobstruction. Inflammation, shock, ischemia, electrolyte disturbances, drugs, hyperglycemia and dysregulated enteral hormones lead to abnormality in gastrointestinal motility physiology like reduced frequency and amplitude of antral contractions, delayed fundic relaxation, loss of gastric and duodenal phase 3 activity promoting retrograde peristalsis, abnormal duodenal contraction and heightened feedback from small intestinal receptors.

Physical examination is insensitive for detection of intraabdominal hypertension. Measurement of pressure using bladder is the mainstay of diagnosis.

Diagnosis of CDI in these patients is difficult as the only specimen available may be a small amount of formed  stool  or  a  swab  of  stool  obtained  either  from  the rectum or from within the colon via endoscopy. In such cases, it is important to communicate to the laboratory the necessity to do a toxin assay or culture for C.  difficile on  the  nondiarrheal  stool  specimen. 
This is the only exception where clostridium difficile test should be done on non-diarrheal stool sample.

Colonoscopy may demonstrate pseudomembrane. 

CT abdomen and pelvis should be done. It may show 'accordion sign' which is the result of alternating haustral folds separated by transverse mucosal ridges, and is typical of clostridium difficile colitis.

Treatment: discontinuing the inciting antimicrobial agent and surgical consultation should be done as early as possible.

Vancomycin administered orally and rectally with intravenously  administered metronidazole is the regimen of choice for the treatment of severe, complicated CDI. The vancomycin dosage is  500  mg  orally  4  times  per  day  and  500  mg  in  approximately  100  mL  normal  saline  per  rectum  every  6  hours as a retention enema, and the metronidazole dosage is 500 mg  intravenously  every  8  hours.

Consider colectomy for severely ill patients. 

Monitoring of  serum  lactate  level  and  the peripheral  blood white  blood  cell  count  may be  helpful  in  prompting  a decision to operate, because a serum lactate level rising to 5  mmol/L  and  a  white  blood  cell  count  rising  to  50,000 cells  per mL  have  been  associated  with  greatly  increased perioperative  mortality.  

Passive immunotherapy with intravenous immunoglobulins (150–400 mg/kg) has been used  for  some  patients  not  responding  to  other  therapies, but no  controlled  trials  have  been  performed.

Other supportive measures includes hemodynamic stabilization with fluid and vasopressors, electrolytes optimization and avoidance of antimotility agents like opiates and loperamide.

Management of raised intraabdominal pressure consists of gastric and rectal decompression, adequate sedation, analgesia and neuromuscular blockage to increase abdominal wall compliance. Head of bed elevation should also be avoided.

References:
Incidence and clinical effect of intraabominal hypertension in critically ill patients. Crit Care Med,2008, June 36.
Guidelines for diagnosis, treatment and preventio of Clostridium difficile infections. Am J Gasteroenterol 2013,April.
Clinical practice guideline for Clostridium difficile infection in adults: 2010 update by IDSA and SHEA.
Intraabdominal hypertension in fulminant Clostridium difficile infection- anMed under recognized treatable complication. Med Sci Monit, 2010,16.

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