Abstract

Introduction: Staphylococcus aureus (S. aureus) was believed to be the likely cause of antibiotic associated enterocolitis in the 1950's and 1960's. Since the 1970's however, Clostridium difficile (C. diff.) has been the prime suspect in antibiotic induced colitis. We describe two cases of C. diff. negative colitis cause by S. aureus: Case 1: 54 yo wf with ulcerative colitis was treated with Asacol for diarrhea and improved. Two weeks after ciprofloxacin for a UTI, she developed sudden worsening with bloody diarrhea and fever. Flagyl was begun but stools tested negative for C. diff. and usual enteric pathogens. High dose steroids were begun. Colonoscopy revealed pancolitis with intense inflammation and deep ulcerations in the ascending colon and ileocecal valve. Bloody diarrhea worsened and repeat stool cultures revealed a pure culture of methacillin-resistant S. aureus (MRSA). Marked improvement occured after IV and oral vancomycin and steroids were rapidly tapered. Oral vancomycin and probiotics alone were continued for 2 weeks, with no relapse of symptoms over the next year. Case 2: 55 yo wm with history of rectosigmoid cancer treated with resection and radiation complicated by mild radiation proctitis and mild stricture presented one month after a course of clarithromycin with sudden abdominal pain, watery diarrhea, and fever to 102F. Colonoscopy revealed a mild rectal stenosis, severe pancolitis, and massive colonic dilation. Stool C. diff. was negative but stool culture revealed S. aureus, sensitive to multiple antibiotics. He was treated with oral vancomycin and probiotics and recovered rapidly. Discussion: The temporal association of antibiotic use in these patients, the lack of stool antigen for C. diff., the pure stool culture for S. aureus, and the rapid improvement with oral vancomycin strongly suggests an etiologic role for S. aureus as the cause of severe colitis in these two cases. The background of inflammatory bowel disease in Case 1 and the radiation proctitis in Case 2 suggests that colonic mucosal immunocomprimise may have predisposed both patients to the S. aureus overgrowth after antibiotic use. Conclusion: S. aureus can cause severe antibiotic associated colitis. Stool cultures testing for S. aureus should be performed in addition to C. diff toxin in patients with suspected antibiotic induced diarrhea. Oral vancomycin and probiotics are effective for S. aureus colitis.

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