Clostridium difficile infection natural history, complications and prognosis

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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

Natural History

1. Carrier Stage

  • Following ingestion of C. difficile spores, patients are colonized with the organism.
  • Typically, young healthy individuals with adequate immune responses are able to clear the organism without development of any clinical manifestations.
  • In contrast, patients with risk factors, such as recent antibiotic use, recent hospitalization, advanced age, or immunodeficiency, are more predisposed to persistent colonization and/or develop signs and symptoms of the infection.
  • The carrier stage may be as short as 2 hours following antibiotic administration to several months.

2. Clinical Manifestations

  • The onset of clinical manifestations may occur within 2 hours up to several months of antibiotic use.
  • Patients typically develop watery diarrhea (possibly bloody) associated with colicky diffuse abdominal pain, nausea, malaise, and fever.
  • Diarrhea typically persists for more than 2 days, and patients commonly develop colitis with or without pseudomembrane formation.

3. Pseudomembranous Colitis

  • If left untreated, patients may develop pseudomembranous colitis, which is characterized by the development of yellowish plaques in the colorectal mucosa.
  • Clinical manifestations include abdominal pain, watery diarrhea, and fever with worsening symptoms, dehydration, and further elevation in the concentration of inflammatory markers.

4. Development of Complications

  • In the minority of patients (approximately 3%), clinical manifestations may persist, and C. difficile infection may have a complicated course.
  • Fulminant colitis, extracolonic manifestations, and death have been more frequently reported since the emergence of the hypervirulent C. difficile strain.

5. Recurrence/Reinfection

  • Approximately one-fourth of patients adequately treated with antimicrobial therapy develop recurrence within 4 weeks of therapy completion.
  • Approximately 30-70% of patients experience recurrent C. difficile infection with a new strain following successul completion of antimicrobial therapy.

Complications

Colonic Complications

  • Fulminant colitis: A relatively rare, but fatal, complication of C. difficile infection. Manifestations typically include worsening abdominal pain, prolonged ileus, megacolon, and fever.

Extracolonic Complications

  • Pseudomembrane formation in small intestine
  • Bacteremia
  • Reactive arthritis
  • Visceral or intra-abdominal abscess
  • Appendicitis
  • Osteomyelitis
  • Empyema
  • Death

Prognosis

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