Diarrea clostridial. Un patógeno nosocomial a tener en cuenta / Clostridial diarrhea. A nosocomial pathogen to take into account

La diarrea clostridial es una enfermedad aguda con compromiso colónico que puede poner en riesgo la vida de un paciente. Su agente etiológico es el Clostridium difficile y se ha asociado al uso indiscriminado y por largo plazo de antibióticos de amplio espectro. Su cuadro clínico es variable, puede ir desde un cuadro de diarrea hasta la perforación colónica, que puede determinar la realización de una colectomía de urgencia o incluso provocar la muerte del enfermo. El diagnóstico de certeza se realiza mediante la detección de la toxina clostridial en materia fecal, por técnicas de inmunoensayo enzimático. La terapéutica se realiza con metronidazol o vancomicina por vía oral. El tratamiento quirúrgico está indicado ante la presencia de megacolon tóxico o perforación intestinal, y en aquellos pacientes con toxicidad sistémica con fracaso de la terapéutica médica. (AU)

Clostridial diarrhea is an acute disease with colonic involvement that can be life-threatening for a patient. Its etiologic agent is the Clostridium difficile and it has been associated with the indiscriminate and long-term use of broad-spectrum antibiotics. Its clinical picture varies from a picture of diarrhea to colonic perforation that can determine the performance of an emergency colectomy or even the death of the patient. The certainty diagnosis is carried out by detecting clostridial toxin in fecal matter by enzyme immunoassay techniques. The therapy is carried out with metronidazole or vancomycin orally. Surgical treatment is indicated in the presence of toxic mega colon, intestinal perforation or in those patients with systemic toxicity with failure of medical therapy. (AU)

Incidence and Clinical Outcomes of Clostridium difficile Infection after Treatment with Tuberculosis Medication

BACKGROUND/AIMS: To determine the incidence and clinical characteristics of tuberculosis (TB) medication-associated Clostridium difficile infection. METHODS: This multicenter study included patients from eight tertiary hospitals enrolled from 2008 to 2013. A retrospective analysis was conducted to identify the clinical features of C. difficile infection in patients who received TB medication. RESULTS: C. difficile infection developed in 54 of the 19,080 patients prescribed TB medication, representing a total incidence of infection of 2.83 cases per 1,000 adults. Fifty-one of the 54 patients (94.4%) were treated with rifampin. The patients were usually treated with oral metronidazole, which produced improvement in 47 of the 54 patients (87%). Twenty-three patients clinically improved with continuous rifampin therapy for C. difficile infection. There were no significant differences in improvement between patients treated continuously (n=21) and patients in whom treatment was discontinued (n=26). CONCLUSIONS: The incidence of C. difficile infection after TB medication was not low considering the relatively low TB medication dosage compared to other antibiotics. It may not be always necessary to discontinue TB medication. Instead, decisions concerning discontinuation of TB medication should be based on TB status.

Diarrea asociada a antibióticos / Antibiotic associated diarrhea

La diarrea asociada a antibióticos es una entidad clínica que ha aumentado de manera considerable los últimos años a nivel mundial. Lo anterior se ha visto favorecido por el incremento en el uso de antibióticos de amplio espectro, los que fundamentalmente alteran la flora intestinal habitual, actuando también por otros mecanismos como la alteración de la motilidad intestinal y acción tóxica directa sobre la mucosa intestinal. La presentación clínica varía desde un cuadro leve hasta de mayor gravedad, llegando incluso a la muerte. Lo anterior dependerá de algunas variables, siendo fundamental el estado inmunitario del paciente. La diarrea asociada a antibióticos por Clostridium Difficile tiene mayor relevancia dado su mayor morbimortalidad. Se han utilizado diversos métodos diagnósticos para evaluar esta patología como así también, diferentes estrategias terapéuticas de enfrentamiento, las que se exponen en la presente revisión

Antibiotic-associated diarrhea is a clinical entity showing a significantly greater presence in past years worldwide. These has been favored by the intensification of treatments based on the use of broad-spectrum antibiotics, which alter intestinal flora and act through other mechanisms like alteration of intestinal motility and direct toxic action on the intestinal mucosa. Clinical symptoms vary from mild to severe and may even cause death. The severity of this condition depends on different variables, mainly the immune status of the patient. Clostridum difficile antibiotic-associated diarrhea is the most relevant since it causes greater mobility and mortality. This article is a review of various diagnostic methods used to evaluate this pathology and multiple therapeutical strategies for management of same.

Colite pseudomembranosa provocada por uso de amoxacilina: relato de caso / Pseudomembranous colitis caused by the use of amoxacillin: case report

A colite pseudomembranosa é uma doença caracterizada por diarreia associada ao uso prévio de antibióticos, sendo provocada por reação inflamatória intestinal às toxinas do Clostridium difficile. Na literatura, os principais antibióticos implicados são a ampicilina, as cefalosporinas e a clindamicina. Contudo, qualquer antibiótico pode estar envolvido, incluindo mesmo a vancomicina e o metronidazol que são frequentemente utilizados no tratamento desta patologia. Este relato descreve um caso de colite pseudomembranosa desencadeada por uso de amoxacilina.

A Case of Pseudomembranous Colitis after Voriconazole Therapy

This is a case report on a 35-year-old man with acute myelogenous leukemia who presented fever and intermittent mucoid loose stool to the emergency center. He had been taking voriconazole for invasive pulmonary aspergillosis. The flexible sigmoidoscopy was consistent with the diagnosis of pseudomembranous colitis.

Diarrea por clostridium difficile / Clostridium difficile-associated diarrhea

Clostridium difficile (CD), es un bacilo gram positivo, anaerobio formador de esporas identificado como la principal causa de diarrea asociado al uso de antibióticos en pacientes hospitalizados. Los dos factores de riesgo más importantes para adquirir esta infección son el uso reciente de terapia antimicrobiana y la exposición al microorganismo productor de toxinas. La epidemiología de la enfermedad asociada a Clostridium difficile (EACD) ha cambiado sustancialmente en la última década, con un incremento sostenido en la incidencia y aparición de casos más severos, refractarios y recurrentes. La EACD abarca un amplio espectro de manifestaciones clínicas, que van de la portación asintomática, pasando por un cuadro de diarrea leve, hasta el desarrollo de colitis fulminante con una elevada tasa de mortalidad. El tratamiento antibiótico estándar es el metronidazol y vancomicina oral, con tasas de respuesta cercanas a un 95 por ciento por ; sin embargo, luego de la aparición de cepas “hipervirulentas” en el año 2003, la tasa de respuesta al metronidazol ha disminuido en forma significativa. Por ello, en los últimos años, se han comunicado una serie de estrategias y estudios con nuevos antimicrobianos con resultados alentadores. La terapia inmunológica pareciera tener un rol importante en la prevención de recurrencias así como en el manejo de pacientes con enfermedad severa. Se revisan aquellos aspectos más importantes relacionados con la infección asociada a CD.

Clostridium difficile (CD) is an anaerobic, gram-positive, spore-forming, toxin-producing bacillus. This is the leading cause of nosocomial diarrhea associated with antibiotic therapy in hospitalized patients. The two major risk factors for C. Difficile associated disease (CDAD) are recent exposure to an antibiotic and exposure to a toxin producing strain of the microorganism. Epidemiology of CDAD has changed substantially in the last decade, with an increase of incidence and occurrence of more severe, refractory and recurrent episodes. CDAD clinical spectrum varies from asymptomatic carriers, going from mild diarrhea to fulminant colitis with a high mortality rate. The standard antibiotic treatment is oral metronidazole and vancomycin, with response rates close to 90 percent, but after the appearance of “hypervirulent” strains in 2003, the response rate has decreased significantly. Therefore, in recent years many trials have reported a series of strategies and studies with new antimicrobial agents with promising results. Immunotherapy appears to play an important role in preventing recurrence and in the management of patients with a severe disease. The present article will review the most important aspects related to the infection associated with CD.

Colite pseudomembranosa / Pseudomembranous Enterocolitis

Os autores fazem uma revisão bibliográfica sobre a etiologia, epidemiologia, diagnóstico e manejo da colite pseudomembranosa

A Case of Pseudomembranous Colitis Associated with Rifampin

Pseudomembranous colitis is known to develop with long-term antibiotic administration, but antitubercular agents are rarely reported as a cause of this disease. We experienced a case of pseudomembranous colitis associated with rifampin. The patient was twice admitted to our hospital for the management of frequent bloody, mucoid, jelly-like diarrhea and lower abdominal pain that developed after antituberculosis therapy that included rifampin. Sigmoidoscopic appearance of the rectum and sigmoid colon and mucosal biopsy were compatible with pseudomembranous colitis. The antitubercular agents were discontinued and metronidazole was administered orally. The patient's symptoms were resolved within several days. The antituberculosis therapy was changed to isoniazid, ethambutol and pyrazinamide after a second bout of colitis. The patient had no further recurrence of diarrhea and abdominal pain. We report here on a case of pseudomembranous colitis associated with rifampin.

A Case of Rifampicin associated Pseudomembranous Colitis / 대한소화기학회지

Pseudomembranous colitis is a dangerous but unusual side effect of antibiotics usage. We report a case of pseudomembranous colitis that developed in a 50-year-old female patient with diabetes mellitus during first line anti-tuberculous therapy including rifampicin. The patient was diagnosed with active pulmonary tuberculosis 70 days earlier. On admission, she suffered intermittent abdominal pain and watery diarrhea for 2 weeks. Colonoscopy revealed exudative, punctuate, raised plaques with skip areas or edematous hyperemic mucosa, and histopathologic findings were consistent with pseudomembranous colitis with typical volcano-like exudate. Symptoms improved on treatment with metronidazole. There was no recurrence after reinstitution of the anti-tuberculous agents excluding rifampicin. In patients with persistent diarrhea receiving anti-tuberculosis treatment, rifampicin associated pseudomembranous colitis should always be kept in mind.

Antibiotic associated diarrhoea and enterocolitis.

C. difficile is the major aetiological agent of AAD and PMC and results from overgrowth of C. difficile already present endogenously or of newly acquired exogenous organisms after suppression of competing gut flora. C. difficile produces two kinds of toxins A and B. These toxins attack the colonic mucosa which becomes necrotic with the formation in fulminating cases of an exudative pseudomembrane. Toxigenic and non-toxigenic strains of C. difficile may be present together in an individual suffering from AAD. There is substantial variation among strains with respect to the quantity of lethal toxin produced. There are several strategies available for the investigation of C. difficile associated disease. Detection of toxins by neutralization with C. sordelli antitoxin is an easy, simple and sensitive method. Methods to deal effectively with silent carriers are not known because the routine administration of antibiotic treatment in an attempt to eradicate the carrier state would in fact boomerang by promoting C. difficile associated enteric disease rather than eliminating C. difficile.

Colitis pseudomembranosa: presentación de cuatro casos / Pseudomembranous colitis: report four cases

Antecedentes: Clostridium difficile es responsable de 25-30 por ciento de la diarreas asociadas a antibióticos. La manifestación más dramática de la infección por este germen es la colitis pseudomembranosa. Métodos: Se reportaron 4 casos de colitis pseudomembranosa y se hace una revisión bibliográfica. Resultados: De los cuatro casos con colitis pseudomembranosa, tres ocurrieron en pacientes mayores de 80 años con enfermedades subyacentes. Todos recibieron cefalosporinas (cefuroxima, ceftriaxona, cefalexina) y uno de ellos, además, clindamicina, previamente al cuadro de colitis. El cuadro clínico se caracterizó por numerosas evacuaciones líquidas con moco (sangre en un paciente), dolor abdominal, náusea, vómito y fiebre. Todos tuvieron leucocitosis con neutrofilia y bandemia. Un paciente cursó con anasarca e hipoalbuminemia, sugestivos de enteropatía perdedora de proteínas. La sigmoidoscopia mostró placas amarillentas, evaludas, cubriendo la mucosa de recto, sigmoides y colon descendente. La respuesta al tratamiento con metronidazol o vancomicina orales fue buena. El metronidazol intravenoso fracasó en un paciente y fue útil en otro. Dos de los cuatro pacientes tuvieron recaídas. La respuesta al tratamiento de las recaídas con metronidazol oral fue buena. Un paciente tuvo dos recaídas respondiendo, finalmente, a metronidazol oral y levaduras de Saccharomyces boulardii. Conclusiones: La colitis pseudomembranosa tiene elevada morbilidad en pacientes debilitados, de edad avanzada. Las recaídas son frecuentes en estos pacientes. Si otros estudios lo corroboran, las levaduras de S. boulardii podrían ser de utilidad en la prevención de esta colitis y en el manejo de sus recaídas

Antineoplastic-associated colitis in Chulalongkorn University Hospital.

Clostridium difficile is well known for causing pseudomembranous colitis. Most cases are associated with the use of antimicrobial agents. Non-antibiotic associated colitis has rarely been reported. The causes of colitis are related to dietary changes, anesthesia, uremia, and various non-antibiotics medications, especially antineoplastic agents. Most responsible antineoplastics in previous reports are methotrexate and 5FU. From July 1993 to August 1994, 34 cancer patients developed acute diarrhea after chemotherapy. Six cases hd chemotherapy-associated colitis. All patients presented with moderate to severe diarrhea and demonstrable C.difficile toxin in fecal specimens and did not receive any antibiotics before the onset of diarrhea. Premier enzyme immunoassay (EIA) was used for toxin A assay because it is easy to perform and needs no special tissue culture laboratory facility. Data from multicenters studies have shown good sensitivity and specificity of the test. We found documented antineoplastics associated colitis, 7 episodes from 35 episodes of diarrhea (20.0%) that had been tested with EIA for toxin A. Five of 6 episodes were 5FU related. One patient had 2 episodes of antineoplastic associated colitis with the same chemotherapy regimen. The underlying malignancies were GI malignancies in 3 of 6 patients. In conclusion, moderate to severe diarrhea in cancer patients after chemotherapy should alert the physician to be aware of a potential fatal complication caused by C.difficile infection. True incidence has been undoubtedly masked by concomitant antimicrobial treatment and physician unawareness. Early recognition, discontinuation of chemotherapy and prompt treatment should be done to reduce morbidity and mortality of this disease.

Antibiotic associated colitis.

It is a prospective study based on 100 consecutive cases of diarrhea following antibiotic therapy admitted to the pediatric services of J.N. Medical College, A.M.U., Aligarh between January to December 1987. They had C. penicillin (50), chloramphenicol (34), ampicillin (34), gentamicin (34), cephalosporin (4) and cotrimoxazole (4) for 3 days to 3 weeks prior to the onset of diarrhea. Apart from routine and special investigations, naked eye and microscopic examination of stool, its culture for pathogens including Cl. difficile were carried out in all cases. Presence of Cl. difficile cytotoxin was demonstrated by observing the cytopathic. Effect on veru cell culture, 18 grew Cl. difficile (14 cyto toxin positive). Frequency of fever, vomiting, abdominal distension, dehydration and duration of diarrhea was not different (p > 0.05) in the two groups. Purge rate and presence of mucus and blood in Cl. difficile positive patients was significantly higher (p < 0.05). Eight Cl. difficile positive (7 cytotoxin+ve) were subjected to endoscopy. Three of them showed P.M. colitis and 2 non specific colitis. Chloromycetin, gentamicin and penicillin were the main culprits responsible for AAC. None of the patients given ampicillin alone suffered from AAC. The mortality was 5%.

Colitis pseudomembranosa y balantidiasis: informe de un caso / Pseudomembranous colitis and balantidiasis: a case report

Presentamos el caso de un paciente de sexo masculino de 52 años de edad, portador de una balantidiasis colónica a la que se asocia una colitis pseudomembranosa posiblemente por antibióticos. En la literatura médica revisada no encotramos publicaciones sobre dicha asociación