C. diff Pseudomembranous Colitis (Diarrhea, Campylobacter, Shigella, EPEC)
- The most
common cause of bacterial diarrhea in children is...Answer
- is a
potentially severe diarrheal disease that occurs following exposure to
antibiotic therapy and subsequent colonic overgrowth of Clostridium difficile,
a gram-positive obligate anaerobic
- The organism
produces five toxins, the most
clinically important of which are
toxins A and B.
- These toxins
bind to receptors on the
colonic mucosa and stimulate an
- Toxin A is
considered the predominant virulence factor.
Toxin A is an enterotoxin that causes
fluid secretion, increased vascular permeability, and inflammation of
Toxin B, a cytotoxin, injures the
Pseudomembranous colitis can develop after the administration of
any antibiotic, even agents
that are used to treat this disorder.
Amoxicillin, because of its frequent use in children, is responsible for most
cases in the pediatric population.
Cephalosporins and clindamycin also
are associated commonly with its development.
other factors, including gastric acidity, intestinal mucus production,
intestinal peristalsis, and the immune response to C difficile infection
influence the likelihood of an individual developing pseudomembranous colitis.
Many neonates and infants (up to 70%) have C difficile isolated from their
stools, yet remain asymptomatic carriers.
- It is
believed that young infants (younger than 6 months)
do not have epithelial cell
receptors for toxin adherence
immunity due to placental maternal antibodies
- or are
protected by maternal colostrum
Spectrum of disease
ranging from acute, self-limited
diarrhea to toxic megacolon.
- The diarrhea
typically begins within 10 days of
antibiotic administration, although some cases begin as late as 6 weeks later.
Approximately 10% of children who are infected with C difficile will develop
onset of severe diarrhea and crampy abdominal pain.
often begin within 1 week of the administration of an antibiotic.
vomiting, and high fever complicate the clinical course.
distension and tenderness are found upon physical examination.
gastrointestinal bleeding is often associated with pseudomembranous colitis,
as are electrolyte imbalances, leukocytosis, metabolic acidosis, and
Colonoscopy reveals small plaques of
yellow-white exudates (pseudomembranes), petechiae, and friability.
Toxic megacolon may occur:
clinical manifestations of C difficile-associated infection include:
- failure to
thrive due to chronic infection without colitis,
acute flare of inflammatory bowel
disease without prior use of antibiotic therapy.
Many cases of C difficile infection resolve simply by discontinuing the
Antiperistaltic medications and corticosteroids may prolong the diarrhea.
Metronidazole is the treatment of
choice for C difficile infection. It is curative in greater than 95% of
cases and is the least expensive therapy.
Vancomycin, which may be more
efficacious than metronidazole, is more expensive and, therefore, is
considered second-line therapy.
bacitracin, cholestyramine, and rifampin are alternate therapeutic agents, but
they are less effective than metronidazole.
Relapses occur in up to 15% of cases,
even after appropriate antibiotic therapy. Symptoms recur 1 to 4 weeks after
discontinuation of therapy.
- A second
course of antibiotic therapy is usually effective.
relapses require the use of an alternative antibiotic, a prolonged duration of
treatment, or use of combination therapy.
experience with probiotic therapy
involving Saccharomyces boulardii and Lactobacillus GG has been encouraging.
Whole bowel irrigation with
polyethylene glycol solution also has been used successfully in the
treatment of chronic intractable C difficile infection.
Bartlett JG. Clostridium difficile: history of its role as an enteric
pathogen and the current state of knowledge about the organism. Clin
Infect Dis. 1994;18(suppl 4):S265-S272
Gorbach SL, Chang TW, Goldin B. Successful treatment of relapsing
Clostridium difficile colitis with Lactobacillus GG. Lancet.
Knoop F, Owens M, Crocker IC. Clostridium difficile: clinical disease
and diagnosis. Clin Microbiol Rev. 1993;6:251-265
McFarland LV, Surawicz CM, Greenberg RN, et al. A randomized
placebo-controlled trial of Saccharomyces boulardii in combination
with standard antibiotics for Clostridium difficile disease. JAMA.