Download PDF
Clin Colon Rectal Surg 2020; 33(02): 082-086
DOI: 10.1055/s-0039-3400474
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Physical, Laboratory, Radiographic, and Endoscopic Workup for Clostridium difficile Colitis

Samantha J. Baker
1   Department of General Surgery, University of Alabama at Birmingham, Birmingham, Alabama
,
Daniel I. Chu
2   Department of Gastrointestinal Surgery, University of Alabama at Birmingham, Birmingham, Alabama
› Author Affiliations Funding The authors do not have any financial disclosures or conflict of interest. This research was not supported by any funding agency.
Further Information

Publication History

Publication Date:
25 February 2020 (online)

Also available at
   Permissions and Reprints

Abstract

Clostridium (reclassified as “Clostridioides”) difficile colitis is a common nosocomial infection associated with increased morbidity and mortality. Like many clinical encounters, a focused history and physical examination will help to guide initial management. Further laboratory testing will assist with diagnosis through stool studies, and blood tests, such as white blood cell counts and serum creatinine, can help to stratify patients into illness severity groups for treatment decisions. Radiographic evaluation can be helpful in patients with severe disease and concern for complicated colitis. Endoscopic evaluation should be carefully considered in patients with suspected mucosal injury secondary to infections and plays a role when an alternative diagnosis is suspected. Treatment options depend on the clinical presentation and can range from antibiotic therapy to emergent surgery to fecal transplantation for recurrent episodes. Care for these patients is often challenging, but through a systemic workup the appropriate treatment may be delivered.

Keywords

Clostridium difficile - C. difficile - pseudomembranous colitis - endoscopy
 

  • References

  • 1 McDonald LC, Gerding DN, Johnson S. , et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis 2018; 66 (07) 987-994
    CrossrefPubMedGoogle Scholar
  • 2 Bartlett JG, Moon N, Chang TW, Taylor N, Onderdonk AB. Role of Clostridium difficile in antibiotic-associated pseudomembranous colitis. Gastroenterology 1978; 75 (05) 778-782
    CrossrefPubMedGoogle Scholar
  • 3 Price SB, Phelps CJ, Wilkins TD, Johnson JL. Cloning of the carbohydrate-binding portion of the toxin a gene of Clostridium difficile . Curr Microbiol 1987; 16 (01) 55-60
    CrossrefPubMedGoogle Scholar
  • 4 Lima AA, Innes Jr DJ, Chadee K, Lyerly DM, Wilkins TD, Guerrant RL. Clostridium difficile toxin A. Interactions with mucus and early sequential histopathologic effects in rabbit small intestine. Lab Invest 1989; 61 (04) 419-425
    PubMedGoogle Scholar
  • 5 Sears CL, Kaper JB. Enteric bacterial toxins: mechanisms of action and linkage to intestinal secretion. Microbiol Rev 1996; 60 (01) 167-215
    PubMedGoogle Scholar
  • 6 Riegler M, Sedivy R, Pothoulakis C. , et al. Clostridium difficile toxin B is more potent than toxin A in damaging human colonic epithelium in vitro. J Clin Invest 1995; 95 (05) 2004-2011
    CrossrefPubMedGoogle Scholar
  • 7 Hecht G, Koutsouris A, Pothoulakis C, LaMont JT, Madara JL. Clostridium difficile toxin B disrupts the barrier function of T84 monolayers. Gastroenterology 1992; 102 (02) 416-423
    CrossrefPubMedGoogle Scholar
  • 8 Alfa MJ, Kabani A, Lyerly D. , et al. Characterization of a toxin A-negative, toxin B-positive strain of Clostridium difficile responsible for a nosocomial outbreak of Clostridium difficile-associated diarrhea. J Clin Microbiol 2000; 38 (07) 2706-2714
    CrossrefPubMedGoogle Scholar
  • 9 Thomas C, Stevenson M, Riley TV. Antibiotics and hospital-acquired Clostridium difficile-associated diarrhoea: a systematic review. J Antimicrob Chemother 2003; 51 (06) 1339-1350
    CrossrefPubMedGoogle Scholar
  • 10 Loo VG, Bourgault AM, Poirier L. , et al. Host and pathogen factors for Clostridium difficile infection and colonization. N Engl J Med 2011; 365 (18) 1693-1703
    CrossrefPubMedGoogle Scholar
  • 11 Kyne L, Sougioultzis S, McFarland LV, Kelly CP. Underlying disease severity as a major risk factor for nosocomial Clostridium difficile diarrhea. Infect Control Hosp Epidemiol 2002; 23 (11) 653-659
    CrossrefPubMedGoogle Scholar
  • 12 Kamthan AG, Bruckner HW, Hirschman SZ, Agus SG. Clostridium difficile diarrhea induced by cancer chemotherapy. Arch Intern Med 1992; 152 (08) 1715-1717
    CrossrefPubMedGoogle Scholar
  • 13 Khanna S, Pardi DS. Clostridium difficile infection: new insights into management. Mayo Clin Proc 2012; 87 (11) 1106-1117
    CrossrefPubMedGoogle Scholar
  • 14 Yan D, Chen Y, Lv T. , et al. Clostridium difficile colonization and infection in patients with hepatic cirrhosis. J Med Microbiol 2017; 66 (10) 1483-1488
    CrossrefPubMedGoogle Scholar
  • 15 Rodemann JF, Dubberke ER, Reske KA, Seo DH, Stone CD. Incidence of Clostridium difficile infection in inflammatory bowel disease. Clin Gastroenterol Hepatol 2007; 5 (03) 339-344
    CrossrefPubMedGoogle Scholar
  • 16 Singh H, Nugent Z, Yu BN, Lix LM, Targownik LE, Bernstein CN. Higher incidence of Clostridium difficile Infection among individuals with inflammatory bowel disease. Gastroenterology 2017; 153 (02) 430-438.e2
    CrossrefPubMedGoogle Scholar
  • 17 Bagdasarian N, Rao K, Malani PN. Diagnosis and treatment of Clostridium difficile in adults: a systematic review. JAMA 2015; 313 (04) 398-408
    CrossrefPubMedGoogle Scholar
  • 18 Drekonja DM, Butler M, MacDonald R. , et al. Comparative effectiveness of Clostridium difficile treatments: a systematic review. Ann Intern Med 2011; 155 (12) 839-847
    PubMedGoogle Scholar
  • 19 Nelson RL, Suda KJ, Evans CT. Antibiotic treatment for Clostridium difficile-associated diarrhoea in adults. Cochrane Database Syst Rev 2017; 3: CD004610
    PubMedGoogle Scholar
  • 20 Gerding DN. Diagnosis of Clostridium difficile--associated disease: patient selection and test perfection. Am J Med 1996; 100 (05) 485-486
    CrossrefPubMedGoogle Scholar
  • 21 Kundrapu S, Sunkesula VC, Jury LA, Sethi AK, Donskey CJ. Utility of perirectal swab specimens for diagnosis of Clostridium difficile infection. Clin Infect Dis 2012; 55 (11) 1527-1530
    CrossrefPubMedGoogle Scholar
  • 22 Peterson LR, Robicsek A. Does my patient have Clostridium difficile infection?. Ann Intern Med 2009; 151 (03) 176-179
    PubMedGoogle Scholar
  • 23 Gerding DN, Johnson S, Peterson LR, Mulligan ME, Silva Jr J. Clostridium difficile-associated diarrhea and colitis. Infect Control Hosp Epidemiol 1995; 16 (08) 459-477
    CrossrefPubMedGoogle Scholar
  • 24 Katz DA, Lynch ME, Littenberg B. Clinical prediction rules to optimize cytotoxin testing for Clostridium difficile in hospitalized patients with diarrhea. Am J Med 1996; 100 (05) 487-495
    CrossrefPubMedGoogle Scholar
  • 25 Luo RF, Banaei N. Is repeat PCR needed for diagnosis of Clostridium difficile infection?. J Clin Microbiol 2010; 48 (10) 3738-3741
    CrossrefPubMedGoogle Scholar
  • 26 Sunenshine RH, McDonald LC. Clostridium difficile-associated disease: new challenges from an established pathogen. Cleve Clin J Med 2006; 73 (02) 187-197
    CrossrefPubMedGoogle Scholar
  • 27 Crobach MJT, Baktash A, Duszenko N, Kuijper EJ. Diagnostic guidance for C. difficile infections. Adv Exp Med Biol 2018; 1050: 27-44
    PubMedGoogle Scholar
  • 28 Gateau C, Couturier J, Coia J, Barbut F. How to: diagnose infection caused by Clostridium difficile . Clin Microbiol Infect 2018; 24 (05) 463-468
    CrossrefPubMedGoogle Scholar
  • 29 Krutova M, Wilcox MH, Kuijper EJ. The pitfalls of laboratory diagnostics of Clostridium difficile infection. Clin Microbiol Infect 2018; 24 (07) 682-683
    CrossrefPubMedGoogle Scholar
  • 30 Sunkesula VC, Kundrapu S, Muganda C, Sethi AK, Donskey CJ. Does empirical Clostridium difficile infection (CDI) therapy result in false-negative CDI diagnostic test results?. Clin Infect Dis 2013; 57 (04) 494-500
    CrossrefPubMedGoogle Scholar
  • 31 Polage CR, Gyorke CE, Kennedy MA. , et al. Overdiagnosis of Clostridium difficile Infection in the Molecular Test Era. JAMA Intern Med 2015; 175 (11) 1792-1801
    CrossrefPubMedGoogle Scholar
  • 32 Bartlett JG. Clinical practice. Antibiotic-associated diarrhea. N Engl J Med 2002; 346 (05) 334-339
    CrossrefPubMedGoogle Scholar
  • 33 Approach to Diagnosis of Clostridium difficile via EIA Screening followed by Reflex NAAT. UpToDate, Inc. https://www.uptodate.com/contents/clostridioides-formerly-clostridium-difficile-infection-in-adults-clinical-manifestations-and-diagnosis?search=c.diff%20testing&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 . Accessed October 31, 2019
    PubMedGoogle Scholar
  • 34 Blossom DB, McDonald LC. The challenges posed by reemerging Clostridium difficile infection. Clin Infect Dis 2007; 45 (02) 222-227
    CrossrefPubMedGoogle Scholar
  • 35 Lamont JT, Kelly CP, Bakken JS. Clostridium difficile infections in adults: clinical manifestations and diagnosis. Available at: https://www.uptodate.com/contents/clostridium-difficile-infection-in-adults-clinical-manifestations-and-diagnosis?topicRef=2698&source=see_link#H7229445 . Accessed October 31, 2019
    PubMedGoogle Scholar
  • 36 Rubin MS, Bodenstein LE, Kent KC. Severe Clostridium difficile colitis. Dis Colon Rectum 1995; 38 (04) 350-354
    CrossrefPubMedGoogle Scholar
  • 37 Kawamoto S, Horton KM, Fishman EK. Pseudomembranous colitis: spectrum of imaging findings with clinical and pathologic correlation. Radiographics 1999; 19 (04) 887-897
    CrossrefPubMedGoogle Scholar
  • 38 Valiquette L, Pépin J, Do XV. , et al. Prediction of complicated Clostridium difficile infection by pleural effusion and increased wall thickness on computed tomography. Clin Infect Dis 2009; 49 (04) 554-560
    CrossrefPubMedGoogle Scholar
  • 39 Lim J, Phillips AW, Thomson WL. An unexpected CT finding in a patient with abdominal pain. BMJ Case Rep 2013 2013. Doi: 10.1136/bcr-2012-007345
    PubMedGoogle Scholar
  • 40 Tedesco FJ. Antibiotic associated pseudomembranous colitis with negative proctosigmoidoscopy examination. Gastroenterology 1979; 77 (02) 295-297
    CrossrefPubMedGoogle Scholar