Pseudomembranous Colitis - Clostridium Difficile

The human digestive system is home to over 1000 species of microorganisms. Our natural gastrointestinal flora are harmless and often beneficial in normal conditions, it aids in the digestion of food and hampers the proliferation of virulent bacteria from abroad. However, when the balance between the microorganisms is hundreds of natural broken, it increases the risk of uncontrolled growth of pathogenic microbes, or capable of causing intestinal infection.

Clostridium difficile under microscope
Clostridium difficile under microscope

One of germs with the greatest potential to cause infection in case of proliferation above normal, is the bacterium Clostridium difficile, an organism capable of causing frames of intense colitis (inflammation of the wall of the colon) and diarrhea.

In this article we will talk about the infection by the bacterium Clostridium difficile and pseudomembranous colitis, a severe form of intestinal infection.

What is Clostridium difficile

The Clostridium difficile is a bacterium producing toxins which is usually present in about 3% of healthy adults and up to 20% of hospitalized patients, particularly those undergoing treatment with antibiotics. In elderly patients admitted to long - term care centers, the infection rate is as high as 50%.

Clostridium difficile is usually harmless in healthy people, because its proliferation is controlled by hundreds of other species of bacteria, fungi and protozoa that inhabit our gastrointestinal tract. However, in people who make repeated or prolonged use of antibiotics, the natural intestinal flora can suffer a serious change, favoring the proliferation of strains causing disease.

Clostridium difficile is a bacterium that does not directly attack the colon. Your problem lies in the fact that it is a producer of irritating toxins to the intestinal wall. When bacteria can multiply uncontrollably, a large amount of toxins are produced, leading to colitis (inflammation of the colon) and profuse diarrhea.

Patients with the bacteria C. difficile eliminate the same in the faeces in the form of spores, which can contaminate the environment (clothing, objects, linens, towels...) and people around. For healthy individuals, as family members, such contamination is of little importance because the immune system and the intestinal flora are able to control the infection. However, in a hospital setting, where there are many frail elderly and people with compromised immune systems, it can lead to colitis outbreaks in several inpatients. Therefore, any patient identified as having Clostridium difficile should be placed in contact isolation until the bacteria is eradicated.

Symptoms of colitis by Clostridium difficile

Infection with C. difficile can cause four different clinical presentations:
1. Asymptomatic carrier : hospitalized patients often undergo changes in their intestinal flora and may turn out to be carriers of the bacteria Clostridium difficile . Are called asymptomatic carriers who have the bacteria, eliminate the same in feces and can contaminate the environment and other patients, but show no symptoms. These patients are usually people with strong immune system, heal themselves weeks after they returned to their home.

2. Diarrhoea by Clostridium difficile: in patients who develop symptoms, diarrhea is the most common clinical manifestation. Colitis caused by C. difficile usually cause severe watery diarrhea, which can cause the patient to have several bowel movements per day. Abdominal cramps, low-grade fever and leukocytosis (increased number of leukocytes in the blood count) are other common manifestations. Fever above 38.5°C is a serious signal.

The colitis C. difficile is usually related to the recent administration of antibiotics. The frame can be started even during the processing or even 5 to 10 days after the end (s) of antibiotic (s). In rare cases, colitis by Clostridium difficile can appear only weeks after the end of treatment.

Antibiotics most frequently implicated in the spread of C. difficile are the fluoroquinolones (eg ciprofloxacin, levofloxacin and norfloxacin), clindamycin, cephalosporins and penicillins. However, almost all antibiotics, including vancomycin and metronidazole, which are commonly used in the treatment of Clostridium difficile , can facilitate the emergence of colitis.

3. Pseudomembranous colitis: colitis is a frame a little more serious than the previous one , with diarrhea that can reach 15 bowel movements daily, more intense abdominal pain and presence of blood and pus in the stool. Its main feature is the presence of a pseudomembrane around the wall of the colon, a finding that is usually identified by colonoscopy.

4. Fulminant colitis: a more serious and fortunately rare, fulminant colitis is a severe inflammation frame, with dilation of the colon and large risk of perforation of the same.

Risk factors for infection by Clostridium difficile

The recent use of antibiotics is the most important risk factor for the multiplication of C. difficile. The higher the activity spectrum, that is, the greater the antibiotic's ability to achieve different types of bacteria, and the longer is the treatment time, the greater the risk of colitis C. difficile. Elderly, hospitalized or institutionalized patients also have high risk of infection by this bacterium. Chronic use of drugs that suppress stomach acid, such as omeprazole, pantoprazole and the like, also seems to increase the risk of contamination by bacteria.

It is important to note that there are other causes of diarrhea caused by antibiotic that have no relation to C. difficile. In fact, most of the non - hospitalized young people who develop diarrhea following the use of a particular antibiotic colitis has no Clostridium difficile.

Diagnosis of Clostridium difficile colitis

Diagnosis of colitis C. difficile should be investigated in all hospitalized patients, or has been discharged recently from hospital, to develop severe diarrhea frame. The recent use of antibiotics is an important tip. Outpatients who have made recent use of multiple antibiotics can also develop the infection.

The diagnosis is usually made by toxins search C. difficile in feces. The presence of toxins in a patient with persistent diarrhea is sufficient for diagnosis.

Where the search toxins from C. difficile is negative, but the clinical suspicion is very high, a colonoscopy may be performed to investigate the presence of pseudomembranes, a finding typical of pseudomembranous colitis.

Treatment of Clostridium difficile colitis

Ironically, the treatment of infection by Clostridium difficile is done with antibiotics. For mild to moderate cases, metronidazole is the antibiotic of choice. In more severe cases, vancomycin, orally, should be the choice.

In cases of fulminant colitis with imminent disruption or already established the colon, surgery must be performed with resection of the affected region.

In patients with recurrent infection with C. difficile , despite adequate treatment with metronidazole or vancomycin, some alternatives can be attempted. The transplantation of feces is a new technique which comprises administering stool from a donor directly into the gastrointestinal tract of the patient through colonoscopy or a gastrointestinal tube. The purpose of this treatment is to restore the natural intestinal flora, preventing C. difficile again multiply.

Following the same reasoning, another option is administration of probiotics, which is a product containing natural fungi bacterium of the intestinal flora. While being simpler, probiotics have inferior results transplantation stool, especially in cases of moderate to severe colitis.
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