Clostridium difficile infection of the small bowel--two case reports with a literature survey

Clostridioides Difficile Enteritis: Case Report and Literature Review

Background: Clostridioides Difficile is a well-known pathogen causing diarrhea of various degrees of severity through associated infectious colitis. However, there have been reports of infectious enteritis mainly in patients with ileostomy, causing dehydration through high-output volume; Case presentation: We report the case of a 46-year-old male patient, malnourished, who presented with high-output ileostomy following a recent hospitalization where he had suffered an ileo-colic resection with ileal and transverse colon double ostomy, for stricturing Crohn’s disease. Clostridioides Difficile toxin A was identified in the ileal output confirming the diagnosis of acute enteritis. Treatment with oral Vancomycin was initiated with rapid reduction of the ileostomy output volume; Conclusion: We report a case of Clostridioides Difficile enteral infection as a cause for high-output ileostomy, successfully treated with oral Vancomycin. We also review the existing literature data regarding this specific localized infection.

Clostridioides difficile Enteritis in Patients Following Total Colectomy-a Rare but Genuine Clinical Entity

Objective

Clostridioides difficile infection (CDI) frequently causes colitis following antibiotic exposure and is a leading cause of gastrointestinal infectious mortality. Infection in the small bowel, C. difficile enteritis (CDE), was previously thought impossible, but case series have challenged this dogma. Clostridioides difficile enteritis prevalence, severity, and potential risk factors are unknown.

Methods

We retrospectively analyzed all total colectomy patients over a 20-year period at our institution. C. difficile enteritis was defined by clinical symptoms and positive C. difficile stool testing after colectomy. We compared CDE cases to controls using multivariable analysis to identify potential CDE risk factors.

Results

C. difficile enteritis occurred in 44 of 855 (5.1%) patients, a median of 130 days after colectomy. Compared to controls, CDE patients were similar in age, gender, and presence of immunosuppression. The majority (64%) had antibiotics <30 days prior to CDE. In multivariable analysis, CDE risk factors included perioperative acid suppression (hazard ratio [HR], 2.52; 95% confidence interval [CI], 1.26–5.04; P = .009), colectomy for inflammatory bowel disease (HR, 2.95; CI, 1.29–6.72; P = .010), colectomy for CDI (HR, 9.95; CI, 2.70–36.63; P ≤ .001), and β-lactam use in the setting of enteral feeds (HR, 17.83; CI, 2.75–115.68; P = .003). C. difficile enteritis presented with severe disease half of the time, with 81.8% requiring hospitalization.

Conclusions

C. difficile enteritis is a rare clinical entity that should be considered in postcolectomy patients presenting with CDI symptoms, even years after surgery. Like traditional CDI, likely CDE risk factors include acid suppression and inflammatory bowel disease. Prior antibiotic use in the setting of enteral feeds may amplify CDE risk. C. difficile enteritis often presents as severe disease and frequently requires hospitalization.

Faecal microbiota transplantation for recurring Clostridium difficile infection in a patient with Crohn's disease and ileorectal anastomosis

Faecal microbiota transplantation (FMT) is increasingly being used to treat refractory and recurring Clostridium difficile infection (CDI). Although FMT appears to be safe and highly effective in patients with a preserved colon and immunocompetence, its use in patients with inflammatory bowel disease (IBD) who are on immunomodulating therapies is controversial. In particular, patients who have undergone colectomy may have different treatment responses to FMT. In this case report, we describe the successful use of FMT in a female patient aged 19 years with Crohn's disease who underwent ileorectal anastomosis following colectomy. She had recurrent CDIs that were refractory to metronidazole, pulse-tapered vancomycin and fidaxomicin treatments. She underwent 2 FMTs, which were performed via sigmoidoscopy; her mother served as a donor. Follow-up was conducted for 12 months and indicated sustained remission of CDI.

Spectrum of Clostridium difficile infections: Particular clinical situations

Incidence, pathogenesis, diagnostic techniques and therapeutic management of CDI have prompted abundant and adequate recent literature. However, report on clinical manifestations of CDI is frequently biased by the type of patients selected, the retrospective nature of many papers, the epidemic or endemic characteristics of the population reported. This article seeks to review some less discussed clinical and epidemiological aspects of CDI trying to include the clinical manifestations of this disease in unselected populations and also including discussion of CDI in specific groups of patients such as patients without colon and rectum, pediatric and critical care patients.

Two Patients with Fulminant Clostridium difficile Enteritis Who Had Not Undergone Total Colectomy: A Case Series and Review of the Literature

Introduction. Clostridium difficile is the most common cause of healthcare associated infectious diarrhea, and its most common clinical manifestation is pseudomembranous colitis. Small bowel enteritis is reported infrequently in the literature and typically occurs only in patients who have undergone ileal pouch anastomosis due to inflammatory bowel disease or total abdominal colectomy for other reasons. Presentation of Cases. We report here two cases in which patients developed small bowel C. difficile enteritis in the absence of these underlying conditions. Discussion. Neither patient had underlying inflammatory bowel disease and both had a significant amount of colon remaining. Conclusion. These two cases demonstrate that small bowel C. difficile enteritis should be included in the differential diagnosis of patients on antibiotic therapy who demonstrate signs and symptoms of worsening abdominal disease during their postoperative course, even if they lack the major predisposing factors of inflammatory bowel disease or history of total colectomy.

Clostridium difficile infection in the postcolectomy patient

Clostridium difficile infection (CDI) after total colectomy has been increasingly recognized over the past decade. C. difficile enteritis (CDE) is a rare occurrence, whereas C. difficile pouchitis (CDP) has been reported in approximately 10% of symptomatic patients seen at a referral center for pouch dysfunction. Similar to colonic CDI in the general population, antibiotic use and comorbid diseases may be risk factors for CDE. In contrast, the postoperative use of antibiotics does not seem to be associated with CDP, whereas male gender, recent hospitalization, and presurgery antibiotic use were shown to be risk factors for CDP. C. difficile is capable of colonizing all intestinal sites, including the ileal pouch. Similarities with the colon at physiological and cellular levels may contribute to the susceptibility of the ileal pouch to CDI. Postcolectomy CDI likely represents a disease spectrum from asymptomatic colonization to severe symptomatic infection. CDI should be considered in ostomy patients with fever and increased ileostomy output and in ileal pouch patients with a change in "normal" symptom pattern or chronic antibiotic-refractory pouchitis. Sensitive and specific methods for detection of CDI are available, and endoscopy is useful in evaluating the patient with suspected CDE or CDP, although pseudomembranes are typically absent. Vancomycin is used as the first-line therapy for CDP and may be warranted for patients with inflammatory bowel disease with CDE. Fecal microbiota transplantation has found its use in the management of severe or antibiotic refractory CDP, but this approach requires evaluation for the management of refractory CDE.

Clostridium difficile enteritis: a new role for an old foe

BACKGROUND

Small bowel involvement of Clostridium difficile is increasingly encountered. Data on many management aspects are lacking.

AIM

To synthesis existing reports and assess the frequency, pathophysiology, outcomes, risk factors, diagnosis and management of C. difficle enteritis.

METHODS

A systematic review of the literature was conducted to evaluate evidence regarding frequency, pathophysiology, risk factors, optimal diagnosis, management and outcomes for C. difficle enteritis. Three major databases (PubMed, MEDLINE and the Cochrane Library) were searched. The review included original articles reporting C. difficle enteritis from January 1950 to December 2012.

RESULTS

C. difficle enteritis is rare but increasingly encountered. Presentation is variable and distinct predisposing factors include emergency surgery, white race and increased age. Diagnosis generally involves a sensitive but often non specific screening test for C. difficile antigens. Oral metronidazole represents first line therapy and surgery may be required for complications. Outcomes are inconsistent but may be improving.

CONCLUSIONS

A high index of clinical suspicion, early diagnosis and treatment are vital. Further prospective studies are needed to determine the significance of asymptomatic small bowel C. difficile infections.

Importance of toxin A, toxin B, and CDT in virulence of an epidemic Clostridium difficile strain

Clostridium difficile infection is the main cause of healthcare-acquired diarrhea in the developed world. In addition to the main virulence factors toxin A and B, epidemic, PCR Ribotype 027 strains, such as R20291, produce a third toxin, CDT. To develop effective medical countermeasures, it is important to understand the importance of each toxin. Accordingly, we created all possible combinations of isogenic toxin mutants of R20291 and assessed their virulence. We demonstrated that either toxin A or toxin B alone can cause fulminant disease in the hamster infection model and present tantalizing data that C. difficile toxin may also contribute to virulence.

Clostridium difficile infection and inflammatory bowel disease

The prevalence of Clostridium difficile infection (CDI) in inflammatory bowel disease (IBD) has become a focus of increased attention, as the C. difficile epidemic continues to grow. Although first documented more than 20 years ago, only in recent years has the relationship between these 2 entities been better clarified, and recent epidemiologic studies have shown that IBD patients are at increased susceptibility for CDI compared with the general population. Despite this increased attention, much still remains unknown, and the overlapping clinical presentations of CDI and IBD pose barriers to diagnosis and standardized treatment. Moreover, given the relationship between mortality and severity of CDI in IBD patients, early recognition of those who are at increased risk for infection is of paramount importance to improve patient outcome.

Clostridium difficile enteritis: A report of two cases and systematic literature review

Clostridium difficile (C. difficile) is the most common cause of healthcare associated infectious diarrhea. In the last decade, the incidence of C. difficile infection has increased dramatically. The virulence of C. difficile has also increased recently with toxigenic strains developing. C. difficile is generally a disease of the colon and presents with abdominal pain and diarrhea due to colitis. However, C. difficile enteritis has been reported rarely. The initial reports suggested mortality rates as high as 66%. The incidence of C. difficile enteritis appears to be increasing in parallel to the increase in colonic infections. We present two cases of patients who had otherwise uneventful abdominal surgery but subsequently developed C. difficile enteritis. Our literature review demonstrates 81 prior cases of C. difficile enteritis described in case reports. The mortality of the disease remains high at approximately 25%. Early recognition and intervention may reduce the high mortality associated with this disease process.

Clostridium difficile in the ICU: the struggle continues

Clostridium difficile infection (CDI) management has become more daunting over the past decade because of alarming increases in CDI incidence and severity both in the hospital and in the community. This increase has concomitantly caused significant escalation of the health-care economic burden caused by CDI, and it will likely be translated to increased ICU admission and attributable mortality. Some possible causes for difficulty in management of CDI are as follows: (1) inability to predict and prevent development of severe/complicated or relapsing CDI in patients who initially present with mild symptoms; (2) lack of a method to determine who would have benefited a priori from initiating vancomycin treatment first instead of treatment with metronidazole; (3) lack of sensitive and specific CDI diagnostics; (4) changing epidemiology of CDI, including the emergence of a hypervirulent, epidemic C difficile strain associated with increased morbidity and mortality; (5) association of certain high-usage nonantimicrobial medications with CDI; and (6) lack of treatment regimens that leave the normal intestinal flora undisturbed while treating the primary infection. The objective of this article is to present current management and prevention guidelines for CDI based on recommendations by the Society for Healthcare Epidemiology of America and Infectious Diseases Society of America and potential new clinical management strategies on the horizon.

[Clostridium difficile enteritis]

INTRODUCTION

Clostridium difficile infection of the small intestine is infrequent.

METHOD

We present the first case of C. difficile enteritis (CDE) diagnosed in Spain and provide a review of the literature.

RESULTS

A 30-year-old man underwent surgery for recurrence of a retroperitoneal germ cell tumor. Seven days later the patient developed vomiting, diarrhea and, finally, intestinal obstruction due to pseudomembranes caused by CDE. Only 57 cases of CDE have been reported in the literature. The mean age was 52±17 years with a range of 18 to 86 years. Twenty-nine patients (50%) had inflammatory bowel disease. Forty-seven (81%) had a history of colon or small intestine surgery. Mortality was higher in older patients and in those without inflammatory bowel disease.

CONCLUSION

CDE is characterized by high severity and mortality.