EP492 - Fulminant Clostridium difficile infection post reversal of ileostomy

Abstract

Abstract Aims Clostridium difficile infection (CDI) is an important cause of diarrhoea in hospitalized patients, varying from mild to fulminant forms. Fulminant CDI subsequent to the reversal of ileostomy, despite negative C. difficile toxin, is rare. Results We present the case of a 75-year-old male with a history of atrial fibrillation, chronic obstructive pulmonary disease and hypertension, who underwent elective ileostomy reversal following an emergency laparotomy and end ileostomy for acute diverticular bleed two years prior. Initially uncomplicated, the patient developed mild CDI on postoperative day 4 with white cell count of 18.6×109/L, evolving rapidly to severe CDI by day 6, characterized by worsening abdominal pain, worsening leukocytosis (30×109/L), and acute kidney injury stage 1. Patient was started on Vancomycin and Metronidazole, Computed Tomography (CT) scan showed uncomplicated sigmoid colitis. Despite aggressive antibiotic therapy and fluid resuscitation, the patient deteriorated on day 8, presenting with fulminant CDI, hypotension, elevated lactate of 2.6 and leukocytes of 46×109/L. Subsequent CT Imaging revealed pneumatosis coli. At that point, the patient's NELA score was 53.4%. The patient was stabilised by the critical care team prior to emergency subtotal colectomy and end ileostomy due to suspected colonic perforation. Surgical finding showed transverse colon inflammation with a hepatic flexure abscess. Patient required 14-day intensive care unit stay and 13 days of ward management before he is fit for rehab. Conclusion This case highlights the potential for fulminant CDI post-ileostomy reversal and highlights the challenges in managing such complications, necessitating prompt recognition and interventions to mitigate adverse outcomes.