Infections: Clostridium Difficile Infection

Epidemiology

• Incidence is increasing with a preponderance of the NAP1 hypervirulent strain of C. difficile found in recent epidemics.
  • The NAP1 strain is more likely to cause severe and fulminant colitis, characterized by marked leukocytosis, renal failure, hemodynamic instability, and toxic megacolon.
  • It is believed the NAP1 strain arose due to the widespread use of fluoroquinolone antibiotics.

Management

• Options:
  1. Oral vancomycin (more effective)
  2. Oral metronidazole
• Neither I.V. vancomycin nor I.V. metronidazole have been found to be more effective than the oral form of the medications for treatment of CDI.
• No role for fluoroquinolones.
• Metronidazole should be avoided in patients on warfarin
  • Metronidazole interferes with warfarin metabolism
• Worsening diarrhea, fever, and leukocytosis despite appropriate antibiotics is an absolute indication for surgical consultation.
  • Subtotal colectomy with end ileostomy is the procedure of choice for fulminant CD colitis nonresponsive to medications and has been documented to result in improved survival.

References

• Wein AJ, Kavoussi LR, Partin AW, Peters CA (eds): CAMPBELL-WALSH UROLOGY, ed 11. Philadelphia, Elsevier, 2015, vol 2, chap 12