Extra-intestinal infections caused by Clostridium difficile

Tubo-ovarian abscess caused by Clostridioides difficile after eight months of surgery: Case report and review of extraintestinal abdominal abscess cases

We present a case of tubo-ovarian abscess (TOA) caused by Clostridioides difficile (CD) in a 43-year-old female. Despite lacking a history of sexually transmitted diseases, the patient had undergone paraovarian cystectomy nine months before admission. Transvaginal ultrasonography performed eight months post-surgery revealed left ovarian enlargement, accompanied by subsequent lower abdominal pain and fever exceeding 38 °C. As oral antibiotic treatment was ineffective, the patient was admitted to our hospital. Computed tomography upon admission revealed a massive TOA. Surgical drainage of the abscess was performed, and CD was identified in the culture from the pus. The TOA was treated with a three-month course of metronidazole and oral amoxicillin/clavulanic acid. While CD is commonly associated with colitis, extraintestinal manifestations are exceptionally rare. This case represents the inaugural report of TOA resulting from CD. A literature review on abdominal and pelvic CD abscesses found that patients undergoing surgical drainage had a favorable prognosis. Therefore, surgical intervention plays an important role in the management of CD abscesses.

Bezlotoxumab prevents extraintestinal organ damage induced by Clostridioides difficile infection

Clostridioides difficile is the most common cause of infectious antibiotic-associated diarrhea, with disease mediated by two major toxins TcdA and TcdB. In severe cases, systemic disease complications may arise, resulting in fatal disease. Systemic disease in animal models has been described, with thymic damage an observable consequence of severe disease in mice. Using a mouse model of C. difficile infection, we examined this disease phenotype, focussing on the thymus and serum markers of systemic disease. The efficacy of bezlotoxumab, a monoclonal TcdB therapeutic, to prevent toxin mediated systemic disease complications was also examined. C. difficile infection causes toxin-dependent thymic damage and CD4⁺CD8⁺ thymocyte depletion in mice. These systemic complications coincide with changes in biochemical markers of liver and kidney function, including increased serum urea and creatinine, and hypoglycemia. Administration of bezlotoxumab during C. difficile infection prevents systemic disease and thymic atrophy, without blocking gut damage, suggesting the leakage of gut contents into circulation may influence systemic disease. As the thymus has such a crucial role in T cell production and immune system development, these findings may have important implications in relapse of C. difficile disease and impaired immunity during C. difficile infection. The prevention of thymic atrophy and reduced systemic response following bezlotoxumab treatment, without altering colonic damage, highlights the importance of systemic disease in C. difficile infection, and provides new insights into the mechanism of action for this therapeutic.Abbreviations: Acute kidney injury (AKI); Alanine Transaminase (ALT); Aspartate Aminotransferase (AST); C. difficile infection (CDI); chronic kidney disease (CKD); combined repetitive oligo-peptides (CROPS); cardiovascular disease (CVD); Double positive (DP); hematoxylin and eosin (H&E); immunohistochemical (IHC); multiple organ dysfunction syndrome (MODS); phosphate buffered saline (PBS); standard error of the mean (SEM); surface layer proteins (SLP); Single positive (SP); wild-type (WT).

Polymicrobial bacteraemia with Clostridioides difficile and Pseudomonas aeruginosa in an elderly man following antibiotic use

Clostridioides difficile is a micro-organism well known to cause pseudomembranous colitis with rare extraintestinal manifestations. We present the case of an elderly male with multiple comorbidities who presented with acute onset of fever/chills and hypotension, found to have polymicrobial bacteraemia with C. difficile and Pseudomonas aeruginosa He was treated with piperacillin/tazobactam for P. aeruginosa bacteraemia, oral vancomycin for C. difficile colitis and intravenous, followed by oral metronidazole for C. difficile bacteraemia. Pseudomonas cleared after 1 day, and Clostridioides cleared after 4 days. Following an initial septic presentation, he responded appropriately to antimicrobial therapy and did well in follow-up.

Polymicrobial Clostridioides difficile lung empyema

Clostridioides (Clostridium) difficile is a well-known cause of enteritis and antibiotic-associated diarrhea. Extraintestinal C. difficile infection is uncommon, with most extraintestinal infections involving the intra-abdominal cavity and anatomic structures adjacent to the colon. Empyema secondary to C. difficile is especially rare, with only a handful of cases reported in the medical literature. A standard antibiotic treatment regimen for C. difficile empyema does not currently exist, and data chronicling successful treatment is limited. We present the case of an 80-year-old woman with a polymicrobial C. difficile empyema who was successfully treated with multiple chest tube insertions and intravenous vancomycin.

Clostridium difficile septic arthritis and periprosthetic joint infection in a patient with acute lymphoblastic leukaemia, T-/B-lymphocytopenia and hypogammaglobulinemia - a case report and review of the literature

To the best of our knowledge, we report the first Clostridium difficile infection in a native hip joint with subsequent prosthetic joint infection in a patient at a state of hypogammaglobulinemia. The infection developed following chemotherapy for B-cell precursor acute lymphoblastic leukaemia (BCP-ALL). After chemotherapy, hip arthroplasty was performed for destructive septic arthritis. However, infection in the hip persisted with several failing revisions for more than 3 years, until ultimately hypogammaglobulinemia and T-/B-lymphocytopenia were diagnosed, and supplementation with i.v. immunoglobulins was able to achieve infection control.

Clostridium difficile appendicitis in an immunocompromised patient: a case report and review of the literature

Background

Clostridium difficile (C. difficile) is a common cause of infectious colitis in individuals with prior antibiotic or hospital exposure. Extraintestinal manifestations of C. difficile infections, however, are rare. Here we present a case of C. difficile appendicitis in an immunocompromised patient.

Case presentation

A 53-year-old Caucasian male presented to the emergency room for two days of lower abdominal pain associated with nausea and subjective fevers. He otherwise denied having diarrhea or hematochezia. He did not have any recent hospitalizations, nursing home stays, or antibiotic exposure. His past medical history was notable for stage III tonsillar squamous cell carcinoma for which he was status post tonsillectomy, radiation therapy, and chemotherapy (cisplatin 4 days prior to presentation). He was afebrile with tenderness to palpation in the bilateral lower quadrants, right greater than left. His white blood cell (WBC) count was 15.6 × 10³ cells/μL. Computed tomography (CT) of the abdomen and pelvis showed marked edema and inflammation of the cecum and ascending colon as well as an enlarged appendix with surrounding inflammatory changes with a small amount of free fluid in the right paracolic gutter. He was treated non-surgically with antibiotics. He did not clinically improve and on hospital day 3, he developed diarrhea for which C. difficile stool polymerase chain reaction was sent. Repeat CT of the abdomen and pelvis was performed which showed progression to pan-colitis and persistent appendicitis. C. difficile testing later resulted positive, for which oral vancomycin was started. The patient markedly improved with medical management alone and was subsequently discharged on oral vancomycin.

Conclusions

Our case highlights the importance of maintaining a high index of suspicion for C. difficile in a patient presenting with both appendicitis and colitis, with prompt diagnosis and treatment being essential.

Extra-Intestinal Effects of C. difficile Toxin A and B: An In Vivo Study Using the Zebrafish Embryo Model

C.difficile infection (CDI) is not a merely “gut-confined” disease as toxemia could drive the development of CDI-related extra-intestinal effects. These effects could explain the high CDI-associated mortality, not just justified by diarrhea and dehydration. Here, the extra-intestinal effects of toxin A (TcdA) and B (TcdB) produced by C. difficile have been studied in vivo using the zebrafish embryo model. Noteworthy, protective properties of human serum albumin (HSA) towards toxins-induced extra-intestinal effects were also addressed. Zebrafish embryos were treated with TcdA, TcdB and/or HSA at 24 h post-fertilization. Embryos were analyzed for 48 h after treatment to check vital signs and morphological changes. Markers related to cardio-vascular damage and inflammation were evaluated by Real-Time quantitative PCR and/or western blotting. Both toxins induced cardiovascular damage in zebrafish embryos by different mechanisms: (i) direct toxicity (i.e., pericardial edema, cardiac chambers enlargement, endothelial alteration); (ii) increased hormonal production and release (i.e., atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP)), (iii) alteration of the vascular system through the increase of the vascular endothelial growth factor (VEGF-A) levels, as well as of its receptors, (iv) pro-inflammatory response through high cytokines production (i.e., CXCL8, IL1B, IL6 and TNFα) and (v) cell-mediated damage due to the increase in neutrophils number. In addition to cardiovascular damage, we observe skin alteration and inflammation. Finally, our data indicate a protective effect of HSA toward the toxins induced extra-intestinal effects. Together, our findings can serve as a starting point for humans’ studies to substantiate and understand the extra-intestinal effects observed in CDI patients.

Clinical characteristics and prognostic factors of extraintestinal infection caused by Clostridioides difficile: analysis of 60 consecutive cases

Data regarding extraintestinal Clostridioides difficile infections (ECDIs) remain scarce and anecdotal. We conducted a retrospective cohort study to investigate characteristics and prognostic factors in patients with ECDI. From January 1997 through December 2018, 60 patients were enrolled and divided into three groups as follows: group A (gastrointestinal [GI] disruption caused by malignancy, n = 13); group B (GI disruption from causes other than malignancy, n = 25); group C (no GI disruption, n = 22). GI disruption was defined as compromised integrity of the GI tract caused by abdominal surgery, perforation, malignancy, enterocolitis, or bleeding. The incidence of ECDI was 2.53 per 100,000 admissions. The most common specimens yielded C. difficile were blood (36.7%), peritoneal fluid (20.0%), and abscesses (16.7%). Six patients (10.0%) had confirmed C. difficile enterocolitis, and 36 patients (60.0%) had a polymicrobial infection. C. difficile bacteremia was significantly more common in group A patients than those in groups B or C (53.8% vs. 48.0% vs. 13.6%, p = 0.02), as was the 30-day mortality rate (69.2% vs. 12.0% vs. 18.2%, respectively; p < 0.001). In multivariate analysis, group A (adjusted odds ratio [aOR], 17.32; 95% confidence interval [CI], 2.96-101.21; p = 0.002) and an age of > 65 years (aOR, 7.09; 95% CI, 1.31-38.45; p = 0.02) were independent risk factors for 30-day mortality. ECDI was uncommonly associated with C. difficile enterocolitis. Two factors, GI disruption caused by malignancy, and old age, were associated with significantly poorer short-term outcomes.

Extraintestinal Clostridioides difficile Infections: Epidemiology in a University Hospital in Hungary and Review of the Literature

Extraintestinal manifestations of Clostridioides difficile infections (CDIs) are very uncommon, and according to the literature, poor outcomes and a high mortality have been observed among affected individuals. The objective of this study was to investigate the incidence rate of extraintestinal infections caused by C. difficile (ECD) in a tertiary-care university hospital in Hungary. During a 10-year study period, the microbiology laboratory isolated 4129 individual strains of C. difficile; among these, the majority were either from diarrheal fecal samples or from colonic material and only n = 24 (0.58%) were from extraintestinal sources. The 24 extraintestinal C. difficile isolates were recovered from 22 patients (female-to-male ratio: 1, average age: 55.4 years). The isolates in n = 8 patients were obtained from abdominal infections, e.g., appendicitis, rectal abscess or Crohn’s disease. These extraintestinal cases occurred without concomitant diarrhea. In all, but two cases C. difficile was obtained as a part of a polymicrobial flora. Our isolates were frequently toxigenic and mostly belonged to PCR ribotype 027. Resistance to metronidazole, vancomycin, clindamycin and rifampin were 0%, 0%, 20.5% and 9.7%, respectively. The increasing amount of reports of C. difficile extraintestinal infections should be noted, as these infections are characterized by a poor outcome and high mortality rate.

Clostridium difficile Infection of a Total Hip Arthroplasty: Case Report and Review of the Literature

CASE

We describe the case of an 85-year-old woman who presented with worsening right hip pain after a conversion hip replacement. Subsequent imaging demonstrated a gas-containing collection in the lateral thigh. She was taken to the operating room for irrigation and debridement, where intraoperative cultures returned positive for Clostridium difficile. Surgical management was followed by a prolonged course of antibiotics.

CONCLUSIONS

Clostridium difficile as the etiology of infection in a conversion arthroplasty is exceedingly rare. Orthopaedic surgeons and infectious disease specialists should consider C. diff as a potential cause of infection in conversion hip arthroplasty because management options will need to be tailored.

Extraintestinal Clostridium difficile infection: Scrotal abscess

Clostridium difficile infection is one of the most common causes of healthcare-associated morbidity and mortality. ExtraintestinalC. difficile infection is extremely rare; though a variety of infections involving different organs have been reported. We report the first case of scrotal abscess due toC. difficile in an 84 year old male following left inguinal herniorrhaphy. Patient underwent surgical drainage of scrotal abscess and was successfully treated with culture directed antibiotic therapy.

Multi-focal Clostridioides (Clostridium) difficile osteomyelitis in a patient with sickle cell anemia: case presentation and literature review

Clostridioides (Clostridium) difficile infection manifests as intestinal infections, namely pseudomembranous colitis. The occurrence of extra-intestinal disease is thought to be rare with a rate of 1.08% of 2034 isolates of C. difficile and an incidence of 4/100,000 admissions. C. difficile had been rarely associated with osteomyelitis. Here, we report the occurrence of C. difficile osteomyelitiin a patient with sickle cell disease. The patient had multiple surgeries and a prolonged antimicrobial therapy to achieve a cure. The patient had C. difficile infection of native bone and of a prosthetic joint. The patient received prolonged therapy with amoxicillin-clavulanic acid and metronidazole and she remained free of C. difficile infection for 3 years off antibiotics.

Clostridium difficile Causing Empyema

Extraintestinal Clostridium difficile infection (CDI) is extremely uncommon. High mortality and poor outcomes have been observed among individuals with this rare medical condition. Empyema is one of the extraintestinal manifestations of CDI. Possible mechanisms to develop this parapneumonic effusion are aspiration and contamination of the chest tube. We present a 42-year-old Hispanic male with C. difficile empyema without any prior history of CDI.

A repeat offender: Recurrent extraintestinal Clostridium difficile infection following fecal microbiota transplantation

Extraintestinal infection with Clostridium difficile has been reported but remains uncommon. Treatment of this unusual complication is complex given the limitations of current therapeutic options. Here we report a novel case of recurrent extraintestinal C. difficile infection that occurred following fecal microbiota transplantation. Using whole genome sequencing, we confirmed recrudescence rather than reinfection was responsible. The patient ultimately responded to prolonged, targeted antimicrobial therapy informed by susceptibility testing.

Invading beyond bounds: extraintestinal Clostridium difficile infection leading to pancreatic and liver abscesses

Clostridium difficile has become a common healthcare-associated infection over the past few years and gained more attention. C. difficile was estimated to cause almost half a million infections in USA in 2011 and 29 000 died within 30 days of the initial diagnosis. Although colitis due to C. difficile is the most common presentation, there have been reported cases of extraintestinal infections. As per our review of literature, this is the third reported case of liver abscess due to the organism.

Acute Appendicitis: An Extracolonic Manifestation of Clostridium difficile Colitis

The current report is the case of a 30-year-old male patient who presented with symptomatology suggestive of appendicitis. However, careful history-taking and laboratory tests led to the diagnosis of Clostridium difficile colitis, resulting in successful nonsurgical management of this patient. Although both appendicitis and C. difficile colitis are common conditions, they are rarely diagnosed concurrently. This is reflected by paucity of literature describing this manifestation. Given this current presentation, the authors contend that the manifestation of extracolonic colitis within the appendix is possibly underdiagnosed or misdiagnosed as an acute appendicitis and thus potentially results in unnecessary surgical intervention. This report reminds physicians to consider the medical approach to managing acute appendicitis given the possibility of underlying C. difficile colitis as the causative factor.

Extraintestinal Clostridium difficile infection due to a ribotype different from that isolated from the feces of the patient: A case report

Extraintestinal infections due to Clostridium difficile are uncommon. When such infections occur, extraintestinal C. difficile isolates are usually identical to fecal isolates. We present a rare case of a large postoperative abscess caused by C. difficile infection, in which different C. difficile strains were isolated from the abscess and from feces of the patient. An 82-year-old woman with cutaneous polyarteritis nodosa developed pain, skin ulcers, and extensive necrosis of the right leg. Above-knee amputation was performed without stopping antiplatelet therapy, leading to postoperative hematoma. Six weeks after surgery, a large femoral abscess was detected and C. difficile was isolated. Repeat amputation of the thigh was required to remove the abscess. C. difficile was also cultured from feces despite the lack of intestinal symptoms. However, genetic analysis confirmed that the C. difficile isolates from the abscess and feces were different strains. Thus, C. difficile can cause postoperative infection of a hematoma and the extraintestinal and fecal C. difficile isolates are not necessarily identical in the same patient.

Clostridium difficile extraintestinal abscess: a rare complication

Extraintestinal Clostridium difficile is rare. A 74-year-old man with a history of ulcerative colitis presented after a fall. Trauma work-up showed liver cirrhosis. Two days later he developed abdominal pain, distension, diarrhoea and leucocytosis. Stool tested positive for C. difficile CT abdomen showed pancolitis with toxic megacolon. Total abdominal colectomy and ileostomy with a rectal stump was performed. He was discharged, but was readmitted with sepsis. CT abdomen showed a 10.4×7.2 cm fluid collection in the pelvis. C. difficile stool was negative. CT-guided abscess drainage grew C. difficile Barium enema was negative for communication from the rectal stump to the abscess. The patient was treated with metronidazole for 2 weeks. In summary, extraintestinal C. difficile can develop from recent antibiotics use, gastrointestinal surgery and microperforations from toxic megacolon. We recommend abscess drainage, concomitant treatment with metronidazole and or vancomycin, and reimaging of abscess location 2-4 weeks after cessation of antibiotics.

Clostridium difficile bacteremia: Report of two cases in French hospitals and comprehensive review of the literature

We report two cases of bacteremia due to Clostridium difficile from two French hospitals. The first patient with previously diagnosed rectal carcinoma underwent courses of chemotherapy, and antimicrobial treatment, and survived the C. difficile bacteremia. The second patient with colon perforation and newly diagnosed lung cancer underwent antimicrobial treatment in an ICU but died shortly after the episode of C. difficile bacteremia. A review of the literature allowed the identification of 137 cases of bacteremia between July 1962 and November 2016. Advanced age, gastro-intestinal disruption, severe underlying diseases and antimicrobial exposure were the major risk factors for C. difficile bacteremia. Antimicrobial therapy was primarily based on metronidazole and/or vancomycin. The crude mortality rate was 35% (21/60).

Clostridium innocuum is a significant vancomycin-resistant pathogen for extraintestinal clostridial infection

OBJECTIVES

Extra-intestinal clostridial infection (EICI) is rare but can be fatal. Traditional phenotypic methods can only assign many of the Clostridium species to the genus level.

METHODS

A total of 376 non-repetitive Clostridium isolates from sterile sites were collected and subjected to matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) Biotyper analysis and 16S rRNA sequencing. Antimicrobial susceptibility was determined, and clinical characteristics of the patients were assessed. Clostridium innocuum isolates were characterized by genome sequencing and genotyping. We used molecular and cellular methods to explore the virulence and resistance mechanisms of C.innocuum.

RESULTS

Clostridium innocuum was the second most common species to cause EICI, only next to Clostridium perfringens. All Clostridium isolates showed susceptibility to clindamycin, metronidazole, penicillin, piperacillin and ampicillin-sulbatam, while C. innocuum isolates were invariably resistant to vancomycin. Among 24 patients with EICI caused by C. innocuum, two (8.3%) had diarrhoea, three (12.5%) had soft-tissue infection, six (25%) had appendicitis and four (16.7%) each had shock and gastrointestinal perforation. The 30-day mortality was 16.7%. The C. innocuum isolated from different sites could not be separated from one another by genotyping. No known toxin genes were identified in the genome of C. innocuum but the species expressed cytotoxicity to epithelial cells. d-Alanine-d-alanine ligase, alanine racemase and d-alanyl-d-alanine carboxypeptidase are three main genes responsible for vancomycin resistance in C. innocuum.

CONCLUSIONS

Vancomycin-resistant C. innocuum is a previously unrecognized, yet prominent, cause for EICI. Genome analysis showed that the species could carry a lipopolysaccharide-like structure that is associated with cytotoxicity to cells in vitro.

[Reactive arthritis due to Clostridium difficile: Report of two cases and literature review]

INTRODUCTION

Reactive arthritis due to Clostridium difficile infection is uncommon.

CASE REPORTS

We report two cases of reactive arthritis associated with C. difficile infection that occurred in a 40-year-old woman and a 47-year-old man. The literature review between 1976 (date of first reported case) and 2016 retrieved 54 observations (including our two cases). Reactive arthritis occurs most frequently in young subjects after a variable time frame according to C. difficile infection, involving one or several articulations. The issue is generally favourable with or without anti-inflammatory treatment.

CONCLUSION

The increasing incidence of C. difficile infection makes more likely the occurrence of this related reactive arthritis. Therefore physicians should consider it in differential diagnosis of bacterial infections capable of causing reactive arthritis.

Fatal community-acquired ribotype 002 Clostridium difficile bacteremia

Extra-colonic infections, and especially bacteremia, are infrequent manifestations of Clostridium difficile infection. C. difficile bacteremia is generally health-care associated and polymicrobial. We report the case of a patient on hunger strike that presented a C. difficile colitis and mono-microbial bacteremia on its admission to the hospital. Multilocus variable number tandem repeat analysis of stool and blood isolates indicated clonality. The strain was characterized as a ribotype 002, an emerging ribotype previously associated with high fatality rate. The patient received treatment by intra-venous amoxicillin-clavulanate and oral vancomycin but eventually died on the seventh day of admission with concomitant pneumonia and pulmonary embolism.

Evaluation of gastrointestinal leakage using serum (1→3)-β-D-glucan in a Clostridium difficile murine model

Gastrointestinal (GI) leakage in Clostridium difficile-associated diarrhea (CDAD) is well known but is not routinely assessed in clinical practice. Serum (1→3)-β-D-glucan (BG), a fungal cell wall component used as a biomarker for invasive fungal disease, was tested in a CDAD mouse model with and without probiotics. Higher serum fluorescein isothiocyanate-dextran (FITC-dextran) and spontaneous gram-negative bacteremia, GI leakage indicators, were frequently found in CDAD mice, which died compared with those which survived. BG, serum macrophage inflammatory protein-2 and FITC-dextran but not quantitative blood bacterial count differentiated the clinical severity. Interestingly, a specific dose of Lactobacillus rhamnosus L34 attenuated CDAD and decreased serum BG and FITC-dextran, but not other parameters. BG also showed a higher area under the receiver operating characteristic curve for 7-day mortality than FITC-dextran. Fifty-five percent of CDAD mice with BG ≥ 60 pg/ml (the human negative cut-off value for invasive fungal disease) at 1 day after C. difficile gavage died within 7 days. In conclusion, S: erum BG was elevated in mice with severe CDAD, an established model of GI leakage with a strong association with mortality rate. BG monitoring in patients with CDAD is of interest as both a potential prognostic tool and a therapeutic efficacy indicator.

Infective thoracic aortic aneurysm caused by Clostridium difficile after endovascular aortic repair

Clostridium difficile generally causes enterocolitis by producing pathogenic toxins, while extraintestinal infections with C. difficile are extremely rare. Here we report the first documented case of an infective thoracic aortic aneurysm caused by nontoxic C. difficile that occurred after vascular interventions including endovascular aortic repair. The present case illustrates that endovascular interventions may expose patients to the rare infection by yielding the ischemic intestinal tract as an entry site for the pathogen into the bloodstream and providing an anaerobic environment inside the thrombosed aneurysm.

The complex factors that contribute to Clostridium difficile infection

Over the past decade Clostridium difficile has emerged as a serious public health issue, causing both hospital-based epidemics and community-associated disease. The most commonly recognised cause of antibiotic-associated diarrhoea in the human population, C. difficile was initially seen as a nuisance pathogen causing limited disease in the hospital setting. However, the emergence of ‘hypervirulent' strain types, associated with an increase in both morbidity and mortality, has made it a pathogen of great concern worldwide. Infection with C. difficile is also being increasingly documented in animals, with suggestions that animals destined for human consumption may provide a reservoir for disease. The use of antibiotics is considered the main risk factor for the development of human infection; however, many other factors such as strain type, patient age, and host immune response all contribute to disease caused by C. difficile.

Extraintestinal Clostridium difficile infections: a single-center experience

OBJECTIVES

To evaluate the clinical burden of extraintestinal Clostridium difficile infection (CDI) seen at a single institution and to characterize the management and outcomes of these rare infections.

PATIENTS AND METHODS

A retrospective medical record review was conducted to identify patients with isolation of C difficile from extraintestinal sites from January 1, 2004, through December 31, 2013. Medical records were reviewed and data, including demographic characteristics, microbiology, clinical associations, management, and infection outcomes, were abstracted.

RESULTS

Overall, 40 patients with extraintestinal CDI were identified: 25 had abdominopelvic infections, 11 had bloodstream infections, 3 had wound infections, and 1 had pulmonary infection. C difficile was isolated with other organisms in 63% of cases. A total of 85% of infections were nosocomial. Factors associated with extraintestinal CDI included surgical manipulation of the gastrointestinal tract (88%), recent antibiotic exposure (88%), malignant tumors (50%), and proton pump inhibitor use (50%). Diarrhea was present in 18 patients (45%), 12 of whom had C difficile polymerase chain reaction (PCR)-positive stool samples. All isolates tested were susceptible to metronidazole and piperacillin-tazobactam. Management included both antimicrobial therapy and guided drainage or surgical intervention in all but one patient. The infection-associated mortality rate was 25%, with death a median of 16 days (range, 1-61 days) after isolation of C difficile.

CONCLUSION

Extraintestinal CDI is uncommon and often occurs in patients with surgical manipulation of the gastrointestinal tract and well-recognized risk factors for intestinal CDI. Management of extraintestinal CDI includes both antimicrobial and surgical therapies. Extraintestinal CDI is characterized by poor outcome with high mortality.

Early infection of hip joint prosthesis by Clostridium difficile in an HIV-1 infected patient

Anaerobes are less frequently described as causative pathogen of prosthetic joint infection (PJI). We report the first case of early PJI after hip arthroplasty due to Clostridium difficile in a diabetic and HIV-1 infected patient with bacteremia. Our patient was successfully treated through surgical debridement and prosthesis retention combined with targeted antibiotic therapy.

Unusual case of prosthetic shoulder joint infection due to Clostridium difficile

Extraintestinal manifestatation such as prosthetic joint infection due to Clostridium difficile is a rare diagnosis. A 47-year-old female patient presented with chronic pain in left shoulder prosthetic joint. Plain roentgenogram of left shoulder prosthetic joint revealed anterior dislocation and loosening of prosthesis. The synovial fluid cultures and intraoperative deep joint cultures repeatedly grew Clostridium difficile. Patient was treated with antimicrobial therapy and surgical debridement with complete removal of hardware and revision arthroplasty.

A case of Clostridium difficile bacteremia in a patient with loop ileostomy

Clostridium difficile, an anaerobic, spore-forming, gram-positive, rod-shaped bacterium, is the most common nosocomial pathogen causing pseudomembranous colitis. C. difficile is not intrinsically invasive and rarely infects extraintestinal sites. The bacterium, therefore, is not commonly detected in blood cultures. Here, we report a case of C. difficile bacteremia in a patient who had underwent loop ileostomy because of rectal obstruction following metastatic colon cancer originated from prostate cancer.

Mycotic Iliac Artery Aneurysm Caused by Clostridium difficile in a Patient with Axillobifemoral Bypass for Leriche Syndrome

A 74-year old man on hemodialysis developed a mycotic aneurysm caused by Clostridium difficile. To the best of our knowledge, this is only the second case of such an aneurysm reported in the literature. He had previously undergone axillobifemoral bypass grafting because of symptomatic infrarenal aortic stenosis. Although no blood flow was detected in his occluded right common iliac artery, it expanded rapidly despite intensive antibiotic therapy. As the blood supply to the lower limbs was already secured, only resection of the infected arteries was performed.

Multidrug-resistant organisms, wounds and topical antimicrobial protection

Multidrug-resistant organisms (MDROs) are increasingly implicated in both acute and chronic wound infections. The limited therapeutic options are further compromised by the fact that wound bacteria often co-exist within a biofilm community which enhances bacterial tolerance to antibiotics. As a consequence, topical antiseptics may be an important consideration for minimising the opportunity for wound infections involving MDROs. The objective of this research was to investigate the antimicrobial activity of a silver-containing gelling fibre dressing against a variety of MDROs in free-living and biofilm states, using stringent in vitro models designed to simulate a variety of wound conditions. MDROs included Acinetobacter baumannii, community-associated methicillin-resistant Staphylococcus aureus, and extended-spectrum beta-lactamase-producing bacteria. Clostridium difficile was also included in the study because it carries many of the characteristics seen in MDROs and evidence of multidrug resistance is emerging. Sustained in vitro antimicrobial activity of the silver-containing dressing was shown against 10 MDROs in a simulated wound fluid over 7 days, and inhibitory and bactericidal effects against both free-living and biofilm phenotypes were also consistently shown in simulated colonised wound surface models. The in vitro data support consideration of the silver-containing gelling fibre dressing as part of a protocol of care in the management of wounds colonised or infected with MDROs.

Two case reports of Clostridium difficile bacteremia, one with the epidemic NAP-1 strain

Clostridium difficile bacteremia is rare. Here, we report two cases of C. difficile bacteremia in patients with significant underlying gastrointestinal pathology. In one case, the bacteremia was caused by the North American pulsed-field gel electrophoresis (PFGE) type 1 (NAP-1) strain, which is responsible for recent outbreaks of C. difficile infections of increased severity.

Bacteraemia and breast abscess: unusual extra-intestinal manifestations of Clostridium difficile infection

Extra-intestinal manifestations of Clostridium difficile infection are uncommon. Most cases are associated with gastrointestinal disease and often occur as a mixed infection with other gut flora. We report a case of breast abscess following monomicrobial C. difficile bacteraemia in a female with background chronic hepatitis C infection and alcoholic liver disease. No evidence of colitis was found. Our case shows that C. difficile is indeed capable of spreading from the gastrointestinal tract.

Clostridium difficile bacteremia, Taiwan

To determine clinical characteristics and outcome of patients with Clostridium difficile bacteremia (CDB), we identified 12 patients with CDB in 2 medical centers in Taiwan; all had underlying systemic diseases. Five had gastrointestinal diseases or conditions, including pseudomembranous colitis (2 patients); 4 recalled diarrhea, but only 5 had recent exposure to antimicrobial drugs. Ten available isolates were susceptible to metronidazole and vancomycin. Five isolates had C. difficile toxin A or B. Of 5 patients who died, 3 died of CDB. Of 8 patients treated with metronidazole or vancomycin, only 1 died, and all 4 patients treated with other drugs died (12.5% vs. 100%; p = 0.01). C. difficile bacteremia, although uncommon, is thus associated with substaintial illness and death rates.