Recurrent Clostridium Difficile Colitis Research Articles

Recurrent Clostridium difficile colitis in elderly: the role of fidaxomicin

Clostridium difficile colitis is a substantial cause of in-hospital morbidity. Since the mortality attributable may be as high as 10%, a prompt and effective treatment is advisable. Fidaxomicin is a well-documented effective drug for the treatment of C. difficile colitis and it is particularly effective in the treatment of recurrences. We report a case of a 92-year-old woman with prolonged hospitalization and recurrent episodes (three in a three-month period) of C. difficile diarrhea. Each episode initially responded to vancomycin. However, after the third episode fidaxomicin was given, with a sustained response (5 months without further episodes). In this patient fidaxomicin was safe and effective in treating recurrence of C. difficile colitis. The use of fidaxomicin as a therapy of first episode of C. difficile colitis should be considered for those patients with a predictable high risk of recurrent C. difficile colitis.

Solid organ recipients are at increased risk for recurrent Clostridium difficile colitis

Background Solid organ transplant (SOT) recipients carry a high risk of developing Clostridium difficile-associated colitis (CDAC) and an increased risk for recurrence.

Recurrent Clostridium difficile Colitis in a Patient with Concurrent Diverticulitis

Background:Clostridium difficile infection (CDI) and diverticulitis both cause inflammation of the colon and mimic each other radiographically. Distinguishing between the two entities is essential, as the treatment for diverticulitis (fluoroquinolone or cephalosporin, in addition to an antibiotic with anaerobic activity) can be a harbinger for CDI. Although rare, both diseases can present simultaneously, making diagnosis and treatment difficult. Case Presentation: A 76-year-old man with a history of recurrent diverticulitis subsequently developed CDI and was referred to us with recurrent symptomatic colitis. In May and November, 2011, he developed left lower quadrant abdominal pain and was treated with ciprofloxacin and metronidazole for 10 days with resolution of symptoms each time. Another episode occurred in December, 2011, but he now developed bloody, watery diarrhea. His stool C. difficile toxin assay was positive, and he was treated with metronidazole for two weeks with resolution of his diarrhea. Three months later, he again developed watery diarrhea, and his stool was positive for C. difficile. He responded to treatment with oral vancomycin followed by a prolonged taper, but within a week of discontinuing the taper, his diarrhea returned and he became dehydrated, requiring hospitalization. His WBC was 15.6 x 10ˆ3/μl. CT scan (June 4, 2012) showed thickening of the distal transverse, descending, and sigmoid colon. Given these findings, he was treated for recurrent sigmoid diverticulitis (ciprofloxacin and metronidazole) and CDI (fidaxomicin followed by a vancomycin taper). Review of his follow-up abdominal CT (June 29, 2012) showed resolution of colitis in the transverse and descending colon, but residual abnormalities in the sigmoid colon. As his symptoms resolved, he continued only a suppressive dose of vancomycin (125 mg once daily). He again became symptomatic (July, 2012) with bloody stools, abdominal cramps, and fever, and was treated for both entities. Although his vancomycin regimen was empirically increased to 250 mg QID, his stool C. difficile assay was negative, and this episode likely represented simple diverticulitis. The patient successfully underwent resection of the sigmoid colon two months later and has had no further symptoms. Conclusion: Management of recurrent CDI and diverticulitis becomes difficult as the antibiotics used to treat the latter are often the culprit in the development of the former. Prior studies suggest that patients with diverticulosis who develop CDI are more prone to CDI, as the diverticula themselves serve as a reservoir for C. difficile spores. In patients with recurrent CDI and concurrent diverticulitis, surgical resection of the latter should be considered.

Alteration of Intestinal Dysbiosis by Fecal Microbiota Transplantation Does not Induce Remission in Patients with Chronic Active Ulcerative Colitis

In patients with ulcerative colitis (UC), alterations of the intestinal microbiota, termed dysbiosis, have been postulated to contribute to intestinal inflammation. Fecal microbiota transplantation (FMT) has been used as effective therapy for recurrent Clostridium difficile colitis also caused by dysbiosis. The aims of the present study were to investigate if patients with UC benefit from FMT and if dysbiosis can be reversed. Six patients with chronic active UC nonresponsive to standard medical therapy were treated with FMT by colonoscopic administration. Changes in the colonic microbiota were assessed by 16S rDNA-based microbial community profiling using high-throughput pyrosequencing from mucosal and stool samples. All patients experienced short-term clinical improvement within the first 2 weeks after FMT. However, none of the patients achieved clinical remission. Microbiota profiling showed differences in the modification of the intestinal microbiota between individual patients after FMT. In 3 patients, the colonic microbiota changed toward the donor microbiota; however, this did not correlate with clinical response. On phylum level, there was a significant reduction of Proteobacteria and an increase in Bacteroidetes after FMT. FMT by a single colonoscopic donor stool application is not effective in inducing remission in chronic active therapy-refractory UC. Changes in the composition of the intestinal microbiota were significant and resulted in a partial improvement of UC-associated dysbiosis. The results suggest that dysbiosis in UC is at least in part a secondary phenomenon induced by inflammation and diarrhea rather than being causative for inflammation in this disease.

PPI Therapy and Albumin are Better Predictors of Recurrent Clostridium difficile Colitis than Choice of Antibiotics

BackgroundRecurrent Clostridium difficile colitis (RCDC) is common, but data regarding recurrence rates and predisposing factors are sparse. MethodsA retrospective case–control study was performed, identifying all inpatients and outpatients ≥18 years of age with C. difficile colitis (CDC) confirmed by a positive stool sample collected at our institution from January 2008 to August 2011. Factors associated with RCDC, the number of RCDC episodes, and the need for admission for RCDC were sought. ResultsA total of 739 patients (male, 47 %) were studied, of whom 527 (71 %) received inpatient treatment for their index episode of CDC. There was no difference (p = 0.53) between RCDC rates for inpatients (17.6 %) and outpatients (19.8 %). While severity score and albumin were associated with RCDC in our population, use of proton pump inhibitors (PPIs) correlated with decreased RCDC (p = 0.006) and decreased need for admission (p = 0.005). The addition of vancomycin to metronidazole therapy did not lower RCDC rates (p = 0.52) or decrease the need for admission (p = 0.78). ConclusionsHypoalbuminemia strongly correlated with higher recurrence rates, while PPI therapy actually reduced RCDC, representing previously underappreciated potential therapeutic targets for lowering CDC recurrence. The addition of vancomycin to metronidazole did not improve RCDC rates.

Recurrent Clostridium difficile colitis in cystic fibrosis: An emerging problem

ObjectiveTo examine the incidence of recurrent Clostridium difficile infection in patients with cystic fibrosis (CF), including patients who had undergone lung transplantation, and review clinical findings in hospitalized patients with C. difficile colitis. MethodsA retrospective chart review was performed to examine the clinical presentation and management of patients with cystic fibrosis (CF) who received care at the University of Wisconsin Hospital and Clinics (UWHC) from 1994 to 2011 and were prospectively identified with C. difficile colitis. ResultsTen cases of C. difficile associated disease (CDAD) occurred in patients with CF followed by our Adult CF Center over a period of 17years, and 4 patients were bilateral lung transplant recipients. Two of the lung transplant recipients had recurrent CDAD that lead to fulminant pancolitis, surgical intervention, and shock. Two patients in the non-transplant group experienced recurrent C. difficile infection that led to fulminant pancolitis with associated systemic inflammatory response syndrome and required colectomy. ConclusionsC. difficile colitis can cause life threatening illness in patients with CF, and symptoms may be subtle and/or atypical and lead to significant delay in diagnosis. Patients with recurrent C. difficile colitis are at high risk of fatal outcome, and empiric therapy should be considered for patients with previous C. difficile colitis even in the absence of disease when broad-spectrum antibiotics are given to treat bacterial infection.

Reactive arthritis induced by recurrent Clostridium difficile colitis

Clostridium difficile colitis is a common infection that can be difficult to resolve and may result in recurrent infections. Reactive arthritis is a rare presentation of this disease and its treatment is not well differentiated in the literature. We describe a case of reactive arthritis occurring in a patient with a history of recurrent Clostridium difficile colitis while currently receiving a taper of oral vancomycin. His arthritis symptoms resolved with corticosteroids and continued treatment with anticlostridial antibiotics.

Recurrent refractory Clostridium difficile colitis treated successfully with rifaximin and tigecycline: A case report and review of the literature

Clostridium difficile colitis infection is on the rise and is considerably increasing the duration of hospital stay, as well as healthcare costs. The management of C. difficile colitis has become more challenging with the increasing failure of therapeutic response to metronidazole and oral vancomycin. Tigecycline is a new glycylcycline that has shown in vitro activity against C. difficile. We report herein a case of C. difficile colitis that failed to improve on a combination of metronidazole and oral vancomycin. The patient subsequently developed a surgical abdomen secondary to refractory C. difficile colitis, but was successfully treated with a combination of rifaximin and tigecycline after she refused to undergo surgical treatment.

Intravenous tigecycline in the treatment of severe recurrent Clostridium difficile colitis

Intravenous tigecycline in the treatment of severe recurrent Clostridium difficile colitis

Early colectomy may be associated with improved survival in fulminant Clostridium difficile colitis: an 8-year experience

Background We hypothesized that colectomy for fulminant Clostridium difficile colitis (CDC) before organ failure would be associated with decreased mortality. Methods Data were retrospectively collected on patients operated on for CDC between 2000 and 2007. Variables examined included age, sex, immunodeficiency, recurrent CDC, vasopressor requirement, acute respiratory failure, acute renal failure, white blood cell count, and stress ulcer prophylaxis. Univariate and multivariate analyses were performed to identify predictors of mortality. Results During this period, 6,841 patients were diagnosed with CDC and 69 patients underwent surgery. Independent predictors of mortality were age >65 years (odds ratio [OR] 6.8, confidence interval [CI] 1.4–32.3, P = .016), acute respiratory failure (OR 5.4, CI 1.6–18.1, P = .007), and acute renal failure (OR 3.8, CI 1.1–13.1, P = .035). Conclusions Colectomy before the development of organ failure is associated with decreased mortality in patients with fulminant CDC, especially in those >65 years old.

Clostridium difficile

Clostridium difficile

Treatment of Clostridium difficile Infection.

With the introduction of broad-spectrum antibiotics into clinical practice, Clostridium difficile infection has become the most common cause of infectious diarrhea in hospitalized patients. Although mild cases may resolve by discontinuing antibiotics, thus allowing re-establishment of colonic microflora, oral metronidazole or vancomycin is indicated if the process is more severe. Metronidazole may be given intravenously, with intracolonic therapeutic levels achieved by excretion of drug into bile and exudation across inflamed tissue. Vancomycin is preferred treatment of severe cases. Bacitracin given orally is a therapeutic alternative and cholestyramine is a useful adjunct. Most patients with diarrhea or colitis caused by C. difficile respond to initial therapy; however, up to 20% experience relapse when treatment is discontinued. Repeating initial therapy for 10 to 14 days is indicated for first relapse. Multiple relapses require prolonged treatment with vancomycin, which may be supplemented with cholestyramine. Saccharomyces boulardii alone or in combination with vancomycin has been reported to be an effective therapeutic alternative for recurrent infection. Intravenous immunoglobulin can be effective in patients with severe recurrent Clostridium difficile colitis and immune deficiency or low pretreatment levels of serum antitoxin. Surgery is indicated only if recurrent infections are severe and associated with serious complications.

Clostridium difficile colitis in patients after kidney and pancreas-kidney transplantation.

Limited data exist about Clostridium difficile colitis (CDC) in solid organ transplant patients. Between 1/1/99 and 12/31/02, 600 kidney and 102 pancreas-kidney allograft recipients were transplanted. Thirty-nine (5.5%) of these patients had CDC on the basis of clinical and laboratory findings. Of these 39 patients, 35 have information available for review. CDC developed at a median of 30 days after transplantation, and the patients undergoing pancreas-kidney transplantation had a slightly higher incidence of CDC than recipients of kidney alone (7.8% vs. 4.5%, P>0.05). All but one patient presented with diarrhea. Twenty-four patients (64.9%) were diagnosed in the hospital, and CDC occurred during first hospitalization in 14 patients (40%). Treatment was with oral metronidazole (M) in 33 patients (94%) and M+oral vancomycin (M+V) in 2 patients. Eight patients had recurrent CDC, which occurred at a median of 30 days (range 15-314) after the first episode. Two patients (5.7%) developed fulminant CDC, presented with toxic megacolon, and underwent colectomy. One of them died; the other patient survived after colectomy. CDC should be considered as a diagnosis in transplant patients with history of diarrhea after antibiotic use, and should be treated aggressively before the infection becomes complicated.

Saccharomyces boulardii stimulates intestinal immunoglobulin A immune response to Clostridium difficile toxin A in mice.

Saccharomyces boulardii is a nonpathogenic yeast that protects against antibiotic-associated diarrhea and recurrent Clostridium difficile colitis. The administration of C. difficile toxoid A by gavage to S. boulardii-fed BALB/c mice caused a 1.8-fold increase in total small intestinal immunoglobulin A levels (P = 0.003) and a 4.4-fold increase in specific intestinal anti-toxin A levels (P < 0.001). Enhancing host intestinal immune responses may be an important mechanism for S. boulardii-mediated protection against diarrheal illnesses.

Treatment of recurrent Clostridium difficile colitis with Lactobacillus GG.

Treatment of recurrent Clostridium difficile colitis with Lactobacillus GG.

Prevention of further recurrences ofClostridium difficile colitis withSaccharomyces boulardii

A patient with six documented episodes of recurrent Clostridium difficile colitis over an eight-month period is described. Relapses of colitis occurred despite treatment with vancomycin, metronidazole, bacitracin, and cholestyramine. Each recurrence appeared to begin successively closer to the end of the previous course of treatment. Four episodes were sufficiently severe to require hospitalization for rehydration. Saccharomyces boulardii, a nonpathogenic yeast, was begun prior to discontinuing vancomycin therapy for the last recurrence and was continued for three months. Serial stool cultures and assays for C. difficile showed persistence of the organism but rapid reduction of high titers of cytotoxin. No further recurrences of diarrhea or colitis were encountered while the patient was taking Saccharomyces boulardii and for 18 months of follow-up after the yeast was discontinued.