Clostridium Difficile the Landmine of Medicine

Abstract

Clostridium difficile infection (CDI) is a rising challenge to the US health system. Many intervention measures were designed and implemented in an attempt to control CDI including antibiotic stewardship, improved hand hygiene and contact isolation. We are presenting a case series of 2 patients with a unique infection source. A 69 years old Caucasian female (CF) scrub nurse (patient 1) who participated in an elective ileostomy reversal of a 77 years old CF (patient 2) with past medical history of sigmoidectomy and diverting ileostomy. Patient 1 had complaints of persistent diarrhea for 4 weeks before the operation (initial evaluation at that time was negative for C. diff). She came to the emergency department complaining of severe abdominal pain and watery diarrhea 12 days after the operation. Her stool PCR was positive for C. diff and she was treated with IV metronidazole and oral vancomycin with great response. She was discharged on oral Vancomycin. Patient 2 complained of abdominal pain, loose bowel movement with blood and white count of 19100 two days post-surgery. Her stool PCR was positive for C. diff. Oral vancomycin was started and then switched to IV metronidazole and tigecycline due to her nausea and vomiting. Unfortunately, in the next 3 days her condition deteriorated and as medical intervention failed she had an exploratory laparotomy leading to total abdominal colectomy. She improved and was discharged on oral vancomycin.Figure 1Figure 2Figure 3CDI is one of the major causes of healthcare associated infections. There has been a steady increase in the morbidity and mortality associated with C diff given the advent of more toxigenic/virulent strains. Studies have established asymptomatic carriage in up to two thirds of the patients with C diff colonization. Acquisition of C diff infection can be through feco-oral, surface or skin contamination with spores that are highly resistant to microbicides. Diagnosis is established using the clinical features, EIA of toxin or GDH and PCR in equivocal cases. Patient one complained of diarrhea initially and tested negative for C Diff by EIA (64% sensitive) and the diagnosis was missed. Being a healthcare worker (HCW) and at high risk of acquiring C. Diff/carrier state, is it prudent to treat empirically, do a PCR to screen for C. diff carrier state in HCW's ? With this case series we review the available literature, the accuracy of tests and raise questions on possible interventions and their overall cost effectiveness.