Clostridioides difficile Colitis

Abstract

A 32-year-old woman presents with 3 days of crampy abdominal pain associated with frequent loose stools. She states that the diarrhea is now bloody and is occurring almost every hour. She was in good health until 2 weeks ago when she was diagnosed with pyelonephritis, treated with a 10-day course of ciprofloxacin. When she finished the antibiotic course a week ago, her urinary symptoms had completely resolved. On physical examination, she appears in moderate distress. Her temperature is 38.7°C and heart rate is 110 beats per minute. Her abdomen is not distended, but she has diffuse tenderness in all four quadrants. The remainder of her examination is normal. Several laboratory diagnostic tests are sent, including a complete blood count, comprehensive metabolic panel, urinalysis, urine and stool cultures, and stool for Clostridioides difficile toxin. You explain to the patient that she most likely has developed C. difficile infection as a complication related to the antibiotic therapy used to treat her kidney infection and give her a prescription for 10 days of p.o. vancomycin. The next day, the laboratory confirms the presence of C. difficile toxin in the stool sample. When seen in follow-up a week later, the patient reports that she is doing well. Her diarrhea has resolved, and she is no longer having abdominal cramps. Nine days later, she returns to the office because her symptoms have recurred. She explains that she is now experiencing moderate abdominal cramps associated with watery stools every 2–3 hours and would like to be tested again for C. difficile infection. She has not felt feverish and has not noted blood in her stool. Her physical examination reveals diffuse abdominal tenderness, without distension or guarding. She has very active bowel sounds. You explain that approximately one in every five people experiences a recurrence after C. difficile infection. While repeat testing is unnecessary, repeat treatment is. You explain that the vast majority of people who experience a recurrence of infection respond completely to a repeat course of treatment, but that a small number of individuals do develop more stubborn disease that requires a change in the therapeutic approach. The patient is re-treated with 10 days of p.o. vancomycin. During follow-up discussions in the office 2 weeks later, and then by phone a month after that, the patient indicates that she has responded well to the second treatment course without signs of additional recurrences.