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{{Clostridium difficile}}
{{Siren|Clostridium difficile infection}}
{{CMG}}
{{Clostridium difficile infection}}
{{CMG}}; {{AE}} {{YD}}


== Overview ==
== Overview ==
In adults, a [[clinical prediction rule]] found the best [[medical sign|signs]] are<ref name="pmid8644759">{{cite journal |author=Katz DA, Lynch ME, Littenberg B |title=Clinical prediction rules to optimize cytotoxin testing for Clostridium difficile in hospitalized patients with diarrhea |journal=Am. J. Med. |volume=100 |issue=5 |pages=487–95 |year=1996 |pmid=8644759 |doi=10.1016/S0002-9343(95)00016-X }}</ref> significant [[diarrhea]] ("new onset of > 3 partially formed or watery stools per 24 hour period"), exposure of antibiotics, [[abdominal pain]], foul stool odor.
Clinical manifestations may range from an asymptomatic course to a severe/fatal presentation. Common symptoms include acute-onset, foul-smelling watery [[diarrhea]], crampy diffuse or lower [[abdominal pain]], low-grade [[fever]], [[malaise]], [[anorexia]], [[nausea]], and [[weight loss]]. Alarming symptoms that may be suggestive of colonic complications of ''C. difficile'' infection include worsening [[abdominal pain]] and [[diarrhea]], [[high-grade fever]], [[dry mucus membranes]], and [[peripheral edema]].
 
The presence of any one of these findings has a [[sensitivity (tests)|sensitivity]] of 86% and a [[specificity (tests)|specificity]] of 45%.<ref name="pmid8644759"/> In a study on hospitalized patients with a prevalence of positive cytotoxin assays of 14%, the [[positive predictive value]] was 20% and the [[negative predictive value]] was 95%.


==History and Symptoms==
==History and Symptoms==
Clinical manifestations can be quite variable.  Some patients are asymptomatic, and others can present critically ill with [[toxic megacolon]].
Clinical manifestations may range from an asymptomatic course to a severe/fatal presentation.  
* Up to 2/3 of infected hospitalized patients are asymptomatic, but shed organisms and contaminate their environment.  These patients are called ''C. Diff'' fecal excretors.  These patients can be treated with [[vancomycin]] or metronidazole, but the bug is often not eradicated in these patients.
* The reason for the variability is not clear and is not accounted for by strain differences.  Host factors are probably important, such as the presence of antitoxin antibodies and colonic toxin receptors. 
* Risk factors for severe [[colitis]] include malignancy, [[Chronic Obstructive Pulmonary Disease]] (COPD), [[immunosuppression]], [[renal failure]], exposure to anti-peristaltic meds and [[clindamycin]].
* Onset is usually during or shortly after a course of antibiotics.  Cases rarely occur even a month after a course of antibiotics.  Rarely patients have no recent history of antibiotics.


Antibiotic-associated diarrhea with ''C. diff'' infection without colitis may present as:
=== Common Symptoms ===
* Acute, foul-smelling watery [[diarrhea]], with a mean of 3-4 stools a day.
* Acute-onset, foul-smelling watery [[diarrhea]] with or without pus. Diarrhea may occasionally be [[Bloody diarrhea|bloody]]. Diarrhea may be relieved by passage of [[stools]].
* Lower [[abdominal pain]], sometimes crampy
* Crampy, diffuse/lower [[abdominal pain]]
* Low-grade [[fever]]
* Low-grade [[fever]]
Antibiotic-associated diarrhea with ''C. diff'' infection with colitis but without pseudomembrane development may present as:
* Profuse, watery diarrhea of 5-15 bowel movements daily
* [[Fever]]
* [[Malaise]]
* [[Malaise]]
* [[Anorexia]]
* [[Anorexia]]
* Lower quadrant [[abdominal pain]] and cramps, relieved by the passage of diarrhea.
* [[Nausea]]
* [[Nausea]]
* [[Dehydration]]
* [[Weight loss]]
* [[Leucocytosis]]
* Fecal [[leucocytes]] present in >50%.  Occult [[bleeding]] not uncommon.
* [[Sigmoidoscopy]] shows a nonspecific diffuse or patchy erthrematous [[colitis]] without pseudomembranes.


Antibiotic-associated diarrhea with ''C. diff'' infection with colitis and pseudomembrane development presents with prominent signs and symptoms as described above and sometimes:
=== Alarming Symptoms Suggestive of Colonic Complications ===
* Rarely patients will develop indolent, subacute [[pseudomembranous colitis]] with a protein-losing state due to the diffuse [[pancolitis]]. Patients may have severe [[hypoalbuminemia]], [[ascites]], peripheral [[edema]], and their only signs/symptoms may be low-grade [[fever]], [[anorexia]] and [[abdominal discomfort]].
Patients with ''C. difficile'' infection may have a complicated clinical course due to either colonic or extracolonic complications. Common colonic complications include pseudomembranous colitis and toxic megacolon. The following list of symptoms demonstrates the alarming symptoms that may be suggestive of colonic complications of ''C. difficile'' infection:
* [[Sigmoidoscopy]] shows pseudomembranes; raised yellow or off-white plaques ranging up to 1 cm in diameter scattered over the colorectal mucosa. Occasionally pseudomembranes will be located in the proximal colon.
* Worsening diffuse/lower [[abdominal pain]]
 
* Foul smelling, [[watery diarrhea]] with or without pus or blood. Diarrhea may be relieved by passage of [[stools]].
Fulminant [[colitis]] is an uncommon complication that occurs in 2-3% of patients with ''C. Diff'', and can results in perforation, prolonged [[ileus]], [[megacolon]], and [[death]]. Patients may present with:
* High-grade [[fever]]
* Severe [[abdominal pain]] and distension
* Dry mouth and mucus membranes due to [[dehydration]]
* Severe [[diarrhea]]; diarrhea may be absent in patients with [[ileus]]
* [[Peripheral edema]] due to [[hypoalbuminemia]]
* [[Fever]], [[chills]]
* Delirium
* [[Lethargy]]
* Coma
* [[Tachycardia]]


==References==
==References==
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[[Category:Gastroenterology]]
[[Category:Gastroenterology]]
[[Category:Needs overview]]
 
[[Category:Grammar]]
[[Category:Bacterial diseases]]
[[Category:Infectious disease]]
 


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Latest revision as of 17:26, 18 September 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Yazan Daaboul, M.D.

Overview

Clinical manifestations may range from an asymptomatic course to a severe/fatal presentation. Common symptoms include acute-onset, foul-smelling watery diarrhea, crampy diffuse or lower abdominal pain, low-grade fever, malaise, anorexia, nausea, and weight loss. Alarming symptoms that may be suggestive of colonic complications of C. difficile infection include worsening abdominal pain and diarrhea, high-grade fever, dry mucus membranes, and peripheral edema.

History and Symptoms

Clinical manifestations may range from an asymptomatic course to a severe/fatal presentation.

Common Symptoms

Alarming Symptoms Suggestive of Colonic Complications

Patients with C. difficile infection may have a complicated clinical course due to either colonic or extracolonic complications. Common colonic complications include pseudomembranous colitis and toxic megacolon. The following list of symptoms demonstrates the alarming symptoms that may be suggestive of colonic complications of C. difficile infection:

References


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