A New, More Virulent Strain of Clostridium Difficile

Abstract

This paper examines the possibility of increasing virulent strains of toxigenic Clostridium difficile causing severe sepsis, shock and subsequent death within 36 hours at a community hospital. We have noted an increase in the incidence of new cases of Clostridium difficile associated diarrhea over the last 5 years. Moreover, we identified a subset of patients, from October 2004 to Febuary 2005, who based on positive toxigenic strains of Clostridium difficile met requirements for severe sepsis and had APACHE II scores of 25 or greater. We observed that the patients presented initially with anuric acute renal failure, acute respiratory failure and subsequent septic shock. They required multiple intravenous pressor agents and eventually died within 36 hours of admission. No other etiology of sepsis was identified and no colonic dilatation was noted. In these patients colectomy was felt not to be a viable option as the mortality is extremely high once patients develop hypotension requiring intravenous pressors agents. It is our opinion that a more virulent strain of Clostridium difficile triggered the inflammatory cascade causing severe sepsis and neither the use of antibiotics nor colectomy would be sufficient to supress the inflammatory response. It was hypothesized that activated protein C might have been a viable option to attempt to supress the inflammatory response, but the patients condition deteriorated much too rapidly. We believe that patients who develop Clostridium difficile associated diarrhea and severe sepsis should be initially treated with oral Vancomycin as a first line. It is our belief also that the management of suspected cases of fulminant colitis should be aimed at targeting the inflammatory cascade with more aggressive measures such as with the use of activated protein C. Colectomy should also be considered whenever feasible. With the possible increasing incidence of a new epidemic strain, the possibility of antibiotic resistance and the changing facets of the toxin itself, we believe that further research is needed to help in the management of this deadly disease.