Treatment options

Ironically, the first line of treatment after diagnosis of C. diff is more ... ANTIBIOTICS!  The type of antibiotic used varies on the severity of infection. For mild to moderate infections flagyl is used. For more severe infection or for recurrent infections vancomycin is used. Surgery is the last resort for those who have suffered from organ failure or severe inflammation that damaged the lining of the GI tract. The damaged part of the tract is then removed.

Unfortunately, up to 20% of patients with C. diff will get sick again. This may be do to the fact that the initial infection never went away or because the patient was reinfected with another strain of the bacteria after the first round of antibiotics. This is called recurrence. Recurrence of a new infection is about 20% and after the first recurrence the chance of continual recurrence is up to 65! Certain populations are at greater risk for recurrence than others. These are:

• An older adult (65+)
• Are taking other antibiotics for a different condition while being treated with antibiotics for C. diff
• Have severe underlying medical disorder such as chronic kidney failure, inflammatory bowel disease or chronic liver disease 

Treatment for recurrent disease can include more antibiotics, which can pretty much just start this vicious cycle. Increasingly, hospitals are looking towards fecal microbiota transplant as a a form of  treatment for patients with recurrent episodes, though it has yet to be approved by the FDA. Fecal microbiota transplant (FMT) is also known as a stool transplant. FMT restores health intestinal 

bacteria by placing another individual's stool in our colon using a colonoscope or nasogastric tube. Donor stools are carefully and repeatedly screened for parasites, viruses, bacteria and certain antibodies before being used for FMT. Below is a video with more information from Mayoclinic:

Clinical Manifestations

The video above describes the most common C. diff infection symptoms. About 20% of hospitalized adults are C. diff carriers. Those who have diarrhea with colitis, can have watery diarrhea up to 10-15 times daily with lower abdominal pain and cramping, low grade fever, and leukocytosis.

Someone can also develop protein losing enteropathy with hypoalbuminemia. What this means is that the bowel wall becomes so inflamed, albumin (a protein in the blood) begins to leak out. With the albumin, water also follows. Patients can develop ascites (fluid buildup in the stomach) and peripheral edema, as a result.

Below is a video of a woman who contracted C. diff. She explains how she got it, what her symptoms were, and how it impacted her life. It is a little longer than the one above, but I found it to be excellent to hear about it from a patient's perspective.

ALWAYS WASH YOUR HANDS! 

Diagnosis of C. Diff

Every nurse, new and seasoned, will tell you that you can diagnose C. diff by the noxious, pungent smell. While memorable, this is NOT the way to diagnosis a patient! If I could, I would emirate the odor across the inter webs, because truly, it is an unforgettable smell.  Below is the clinical way to diagnose C. diff.

Before you do any testing on your patient, there needs to be present a clinically significant amount of diarrhea or a pause in your GI motility (lack of peristalsis, medically known as ileus). There are diagnostic procedures that can be used to test for C. diff. One of which can be a endoscopic finding of "pseudomembranous colitis". Here is a video to exhibit what an endoscopy would look like and what this colitis is and looks like through a camera lens. 

What is the preferred method for diagnosis is lab testing of the diarrhea. Because the diarrhea is tested for a positive C. difficile toxin, which degrade at room temperature, it is critical that collected swabs are kept at 4 degrees Celsius after collection. The stool that is collected is used in a number of tests including:

• Polymerase chain reaction (PCR) : Detects Toxin A and B genes; tests are highly sensitive and specific. Results are quick, but because of the sensitivity of the tests, false positive results. This test is usually favored for initial diagnosis, while the doctors wait for secondary results that take longer to produce.
• Enzyme immuno assay (ELISA) for C. diff glutamate dehydrogenase (GHD): GDH antigen is an enzyme produced by all C. diff bacterial types. Unfortunately this enzyme is produced by all toxin producing and non-toxin producing C. diff. 
• ELISA for C. diff toxins A and B: Most C. diff strains produce both these toxins. Sensitivity is about 75%, but can be as specific as high as 99%. What this essentially means is that there is relatively high false negative unless a lot of the bacteria has been collected. This is inexpensive and results are within hours. 
• Cell culture cytotoxic assay: This is the gold standard. It is performed by adding a prepared stool sample to a petri dish with a layer of cells. If the C. diff toxin is present, the first layer if cells begins to change shape from a long stretched on cell to a round cell. This test is expensive and takes time.

Early diagnosis is key here in order to ensure patient safety of the individual diagnosed but other individuals on a hospital floor. Immediate isolation is required. In some cases, patients are put into isolation while results are pending. 

So remember, ALWAYS WASH YOUR HANDS.