Fatal Clostridium difficile infection of the small bowel after complex colorectal surgery

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.

Human intestinal enteroids as a model of Clostridioides difficile-induced enteritis

Clostridioides difficile is an important nosocomial pathogen that produces toxins to cause life-threatening diarrhea and colitis. Toxins bind to epithelial receptors and promote the collapse of the actin cytoskeleton. C. difficile toxin activity is commonly studied in cancer-derived and immortalized cell lines. However, the biological relevance of these models is limited. Moreover, no model is available for examining C. difficile-induced enteritis, an understudied health problem. We hypothesized that human intestinal enteroids (HIEs) express toxin receptors and provide a new model to dissect C. difficile cytotoxicity in the small intestine. We generated biopsy-derived jejunal HIE and Vero cells, which stably express LifeAct-Ruby, a fluorescent label of F-actin, to monitor actin cytoskeleton rearrangement by live-cell microscopy. Imaging analysis revealed that toxins from pathogenic C. difficile strains elicited cell rounding in a strain-dependent manner, and HIEs were tenfold more sensitive to toxin A (TcdA) than toxin B (TcdB). By quantitative PCR, we paradoxically found that HIEs expressed greater quantities of toxin receptor mRNA and yet exhibited decreased sensitivity to toxins when compared with traditionally used cell lines. We reasoned that these differences may be explained by components, such as mucins, that are present in HIEs cultures, that are absent in immortalized cell lines. Addition of human-derived mucin 2 (MUC2) to Vero cells delayed cell rounding, indicating that mucus serves as a barrier to toxin-receptor binding. This work highlights that investigation of C. difficile infection in that HIEs can provide important insights into the intricate interactions between toxins and the human intestinal epithelium.NEW & NOTEWORTHY In this article, we developed a novel model of Clostridioides difficile-induced enteritis using jejunal-derived human intestinal enteroids (HIEs) transduced with fluorescently tagged F-actin. Using live-imaging, we identified that jejunal HIEs express high levels of TcdA and CDT receptors, are more sensitive to TcdA than TcdB, and secrete mucus, which delays toxin-epithelial interactions. This work also optimizes optically clear C. difficile-conditioned media suitable for live-cell imaging.

Clostridium difficile enteritis: diffuse small bowel radiological changes in a patient with abdominal sepsis

While imaging appearances of pseudomembranous colitis are commonly recognised, radiological manifestations of Clostridium difficile-associated enteritis are poorly understood which, combined with the rarity of this infection involving small bowel, makes establishing the correct diagnosis challenging. Therefore, in order to encourage awareness of readers, we present a case of C. difficile enteritis that manifested as abdominal sepsis complicating the postoperative period in a middle-aged woman with fistulating Crohn's disease and defunctioning ileostomy. Radiological appearances are described based on three consecutive CT studies performed 5 days prior to onset of symptoms, during the peak of enteritis, corresponding with the patient's clinical deterioration, and also 35 days later following treatment and resolution.

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.

Fecal microbiota transplantation: from the 4th century to 2013

Intestinal microbiota has been defined as a dynamic human organ. Many diseases occur as a result of the disorder of intestinal microbiota. Human fecal microbiota transplantation (FMT), which was originally reported in China in the 4^th century, has become popular in recent years, since it shows an amazing effect in the treatment of pseudomembranous colitis and recurrent Clostridium difficile infection (CDI). It has not only been proposed as a first-line treatment for recurrent CDI but also been utilized to treat inflammatory bowel disease, irritable bowel syndrome, metabolic syndrome, and chronic fatigue syndrome. The mechanism behind the therapeutic effects of FMT is still unclear. The most widely accepted hypothesis is that FMT can use the whole intestinal microbiota from a healthy donor to replace the patient's disordered gut microbiota. At present, FMT is still in the beginning stage, and there is an urgent need to develop standardized protocols and to conduct safety analysis. This review tries to present the past, present and future of FMT by introducing the relationship between gut flora and diseases and the utilization of FMT.

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 of the ileum following total abdominal colectomy, with or without proctectomy: who is at risk?

BACKGROUND

Clostridium difficile enteritis is considered a rare entity, although recent data suggest a significant increase in prevalence and incidence. There is paucity of data evaluating risk factors of C difficile enteritis following total colectomy.

OBJECTIVE

The aim of this study was to determine the incidence and risk factors of C difficile enteritis for patients who had undergone total abdominal colectomy with or without proctectomy.

DESIGN

This study involves a retrospective chart review of 310 patients. Univariate analysis was performed on potential risk factors (p ≤ 0.05) with the use of a logistic regression model, and a Fisher exact test was used for variables that had no occurrences of C difficile. These groups of variables were then examined in a multiple variate setting with stepwise logistic regression analysis.

SETTINGS

This study was conducted at a tertiary referral center.

PATIENTS

A data analysis was performed on patients who had undergone total abdominal colectomy with or without proctectomy who were tested for C difficile of the ileum.

RESULTS

Twenty-two of 137 patients that were tested (16%) were positive for C difficile of the ileum. Univariate analysis of known risk factors for C difficile demonstrated that black race was a protective factor against C difficile (p = 0.016). The multivariate analysis demonstrated that emergency surgery (p = 0.035), race (p = 0.003), and increasing age by decade (p = 0.033) were risk factors for C difficile.

LIMITATIONS

This study was limited by the small patient sample, and it was not a randomized trial.

CONCLUSIONS

Black race is protective, and whites are 4 times more likely to acquire C difficile of the ileum after undergoing a total abdominal colectomy with or without proctectomy. The data also demonstrated that an increased age by a decade and emergency surgery are risk factors for C difficile enteritis, whereas the described risk factors of C difficile of the colon and type of colon surgery do not appear to influence the risk of C difficile of the ileum.

[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.

Clostridium difficile enteritis: a review and pooled analysis of the cases

INTRODUCTION

Clostridium difficile is the most common cause of healthcare-associated infection diarrhea and usually restricted to infection of the colon. However, small bowel involvement of C. difficile infection has been reported. We performed a literature review and pooled analysis of the reported cases of C. difficile enteritis

METHOD

A Pubmed literature database search and pooled analysis of the reported cases of C. difficile enteritis.

RESULTS

56 cases of C. difficile enteritis have been reported from 1980 to 2010; 48 cases were published since 2001. Median age was 55 years. 27 patients (48.2%) were female. 29 patients (51.8%) had inflammatory bowel disease (IBD) - Crohn's disease or ulcerative colitis and 20 patients (35.7%) had predisposing medical condition(s) that might lead to an immunoincompetent state. 33 patients (58.9%) had colectomy with ileostomy and 13 patients (23.2%) had other small and/or large bowel surgery. Thirty four patients (60.7%) received ICU management and 18 patients (32.1%) died. We categorized the patients into two groups, 38 survivors (67.9%) 18 non-survivors (32.1%). Significantly older age was noted in non-survivors. Median age was 48 years and 66 years, respectively for survivors and non-survivors, P < 0.001. There were more patients with predisposing medical condition(s) among non-survivors, (13/18, 72.2%) than among survivors (7/38, 18.4%), P < 0.001.

CONCLUSIONS

C. difficile enteritis is still rare, however it seems to be increasingly reported in recent years. Surgically altered intestinal anatomies, advanced age, predisposing medical condition(s) that might lead to immunoincompetence appear to be at risk for developing C. difficile enteritis. Recognition of C. difficile infection not only in the colon but also in the small bowel may lead to improved outcomes.

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

INTRODUCTION

Diseases associated with Clostridium difficile range from antibiotic-related diarrhea to pseudomembranous enterocolitis, and are serious nosocomial infections with high morbidity and mortality. The C. difficile infection has thus far been regarded as a disease typically affecting the colon. However, the literature contains an increasing number of reports describing infections of the small bowel with fulminant clinical courses and high mortality rates of 60-83%. We think this situation is not very well known.

METHODS

We present two cases of confirmed C. difficile enteritis and a survey of the literature.

CONCLUSION

C. difficile enteritis is characterized by a rising incidence, a sometimes fulminant clinical course, and high mortality rates. Early diagnosis of the disease by toxin detection and endoscopy is of paramount importance and can play a substantial role in improving outcomes.

Fatal Clostridium difficile enteritis caused by the BI/NAP1/027 strain: a case series of ileal C. difficile infections

Clostridium difficile generally causes diarrhoea and colitis. Small-bowel infections are considered to be rare. Twelve cases of ileal C. difficile infections are presented, including the first reported case proven to be caused by the hypervirulent BI/NAP1/027 strain. This case series suggests that small bowel involvement in C. difficile infections may be more frequent than previously thought.

A description of CT features of Clostridium difficile infection of the small bowel in four patients and a review of literature

Clostridium difficile associated disease is an increasingly common cause of morbidity and mortality. Pseudomembranous colitis following hospital-administered antibiotic treatment is the most common symptomatic manifestation. Small bowel enteritis caused by C. difficile, however, is rarely described. Here, we present a series of four patients with hospital-acquired small bowel enteritis caused by C. difficile, discuss its CT and histopathological features, and review the current literature.

Clostridium difficile enteritis in a patient after total proctocolectomy

Clostridium difficile infection is associated with antibiotic therapy and usually limited to the colonic mucosa. However, it is also a rare cause of enteritis, with only a few cases reported in the literature. In the present report, the case of a 30-year-old woman with Clostridium difficile enteritis who previously had a panproctocolectomy with end ileostomy for severe ulcerative colitis is described. Previously reported cases of Clostridium difficile enteritis are also reviewed. Previous antibiotic therapy had been present in all cases and appears causative, major colonic resection is a precipitating factor. Small bowel Clostridium difficile infection should be considered in any patient with ileostomy flux/diarrhoea after major colonic surgery. If recognised early and treated aggressively the high mortality associated with Clostridium difficile enteritis may be avoided.

Thinking beyond the colon-small bowel involvement in clostridium difficile infection

Small intestinal Clostridium difficile seems to be increasing in incidence. The spectrum of Clostridium difficile infection (CDI) has definitely expanded with small bowel involvement. They are more frequently reported in patients with inflammatory bowel disease (IBD) who have undergone total colectomy or patients with Ileal anal pouch anastomosis. The most common presentation is increased ileostomy output with associated dehydration. High clinical suspicion, early recognition and appropriate treatment are the keys to successful resolution. The increase in the number of these patients may actually reflect an increase in the rising incidence of CDI in general or increasing virulence of the organism. Heightened public awareness and initiation of prompt preventive measures are the keystones to control of this infection. This disease is no longer limited to the colon and physicians should be educated to think beyond the colon in patients with CDI.

Fulminant Clostridium difficile enteritis after proctocolectomy and ileal pouch-anal anastamosis

Clostridium difficile (C. difficile) infection of the small bowel is very rare. The disease course is more severe than that of C. difficile colitis, and the mortality is high. We present a case of C. difficile enteritis in a patient with ileal pouch-anal anastamosis (IPAA), and review previous case reports in order to better characterize this unusual condition.

Clostridium difficile and inflammatory bowel disease

Clostridium difficile colitis has doubled in North America over the past 5 years and recent reports have demonstrated an increase in incidence and severity of these infections in patients with inflammatory bowel disease (IBD; Crohn's disease, ulcerative colitis). Studies from single institutions as well as trends identified in nationwide inpatient databases have shown that IBD patients with concomitant C. difficile infection experience increased morbidity and mortality. Results from our center have shown that over half of C. difficile-infected IBD patients will require hospitalization and the colectomy rate may approach 20%. Because C. difficile colitis will both mimic and precipitate an IBD flare, it is essential that clinicians be vigilant to identify and address this infectious complication, as empiric treatment with corticosteroids without appropriate antibiotics may precipitate deterioration. The majority of IBD patients appear to contract C. difficile as outpatients, and a prior history of colitis appears to be the most significant risk factor for acquiring this infection. In addition to C. difficile colitis, IBD patients are now known to be at risk for C. difficile enteritis as well as infections in reconstructed ileoanal pouches. An additional challenge facing C. difficile infections in IBD patients is the decreased efficacy of metronidazole, and the need for oral vancomycin in patients requiring hospitalization. In this review we summarize the present knowledge regarding C. difficile infection in the setting of IBD, including unique clinical scenarios facing IBD patients, diagnostic algorithms, and treatment approaches.

Treatment of metronidazole-refractory Clostridium difficile enteritis with vancomycin

BACKGROUND

Clostridium difficile infection of the colon is a common and well-described clinical entity. Clostridium difficile enteritis of the small bowel is believed to be less common and has been described sparsely in the literature.

METHODS

Case report and literature review.

RESULTS

We describe a patient who had undergone total proctocolectomy with ileal pouch-anal anastomosis who was treated with broad-spectrum antibiotics and contracted C. difficile refractory to metronidazole. The enteritis resolved quickly after initiation of combined oral vancomycin and metronidazole. A literature review found that eight of the fifteen previously reported cases of C. difficile-associated small-bowel enteritis resulted in death.

CONCLUSIONS

It is important for physicians who treat acolonic patients to be aware of C. difficile enteritis of the small bowel so that it can be suspected, diagnosed, and treated.

Clostridium difficile enteritis: an early postoperative complication in inflammatory bowel disease patients after colectomy

Clostridium difficile, the leading cause of hospital-acquired diarrhea, is known to cause severe colitis. C. difficile small bowel enteritis is rare (14 case reports) with mortality rates ranging from 60 to 83%. C. difficile has increased in incidence particularly among patients with inflammatory bowel disease. This case series of six patients from 2004 to 2006 is the largest in the literature. All patients received antibiotics before colectomies for ulcerative colitis and developed severe enteritis that was C. difficile toxin positive. Three patients underwent ileal pouch anal anastomosis and loop ileostomy. Four of the six patients had C. difficile colitis before colectomy. Presenting symptoms were high volume watery ileostomy output followed by ileus in five of six patients. Four of the six patients presented with fever and elevated WBC. Five of the six developed complications requiring further surgery or prolonged hospitalization. Patients were treated with intravenous hydration and metronidazole then converted to oral metronidazole and/or vancomycin. None of the patients died. A high suspicion of C. difficile enteritis in patients with inflammatory bowel disease and history of C. difficile colitis may lead to more rapid diagnosis, aggressive treatment, and improved outcomes for patients with C. difficile enteritis.

Antimicrobial therapy of Clostridium difficile-associated diarrhea

Clostridium difficile-associated diarrhea (CDAD) is the most common etiologically-defined cause of hospital-acquired diarrhea. Caused by the toxins of certain strains of C difficile, CDAD represents a growing concern, with epidemic outbreaks in some hospitals where very aggressive and difficult-to-treat strains have recently been found. Incidence of CDAD varies ordinarily between 1 to 10 in every 1,000 admissions. Evidence shows that CDAD increases morbidity, length of stay, and costs. This article described the clinical manifestations of CDAD, related risk factors, considerations for confirming CDAD, antimicrobial and non-antimicrobial treatment of CDAD, and issues related to relapses. The article concludes with a discussion of recent epidemic outbreaks involving CDAD.