Intravenous immunoglobulin for the treatment of severe, refractory, and recurrent Clostridium difficile diarrhea.

PURPOSE: Clostridium difficile diarrhea is common in elderly patients and leads to prolonged hospitalization. Patients with severe or recurrent Clostridium difficile diarrhea have poor antitoxin antibody responses. Intravenous immunoglobulin has been advocated in these patients. This study was designed to assess the response of patients with refractory, recurrent, or severe Clostridium difficile diarrhea to intravenous immunoglobulin. METHODS: Retrospective review (November 2003-January 2005) of 14 patients with severe, refractory, recurrent Clostridium difficile diarrhea treated with intravenous immunoglobulin (Flebogamma, 150-400 mg/kg) from 264 Clostridium difficile toxin-positive patients. RESULTS: Median age was 79 (range, 54-91) years. Median length of symptoms before intravenous immunoglobulin was 29 (range, 3-90) days. Patients received a median of three (range, 1-5) courses of vancomycin or metronidazole before intravenous immunoglobulin. All had hypoalbuminemia (median, 22 g/l; range, 18-33) and raised C-reactive protein (median, 47 mg/l; range, 25-255) at time of infusion. The median white cell count was 15.3 x 10(9)/liters (range, 4-24). Eight patients had evidence of pancolitis on abdominal imaging, suggesting severe Clostridium difficile diarrhea. All patients tolerated intravenous immunoglobulin without side effects. Nine (64 percent) responded with bowels normalizing in a median of ten (range, 2-26) days; one patient received two doses. One patient had a partial response from two doses but died two months later after a recurrence. The other four patients died of other causes within three weeks of infusion. CONCLUSIONS: Intravenous immunoglobulin may be effective for severe, refractory, or recurrent Clostridium difficile diarrhea after failed conventional treatment.

Postoperative methicillin-resistant Staphylococcus aureus enteritis following hysterectomy: a case report and review of the literature.

Following a hysterectomy a 43-year-old woman developed colicky abdominal pain and profuse postoperative diarrhoea. Examination was unremarkable and initial investigations revealed a normal plain abdominal X-ray initially, but later there was some small bowel dilatation and evidence of raised inflammatory markers. No cause was identified at exploratory laparotomy 2 days post operation. Flexible sigmoidoscopy was normal. The patient was empirically treated with oral vancomycin for presumed Clostridium difficile diarrhoea, although subsequent stool cultures were negative for the usual intestinal pathogens and C. difficile toxin. The diarrhoea persisted for 9 days. By day 10 stool cultures had grown methicillin-resistant Staphylococcus aureus, establishing the diagnosis. To our knowledge this is the first report of methicillin-resistant S. aureus enteritis following hysterectomy.

Urgent cancer referral guidelines: a retrospective cohort study of referrals for upper gastrointestinal adenocarcinoma.

Dyspepsia in primary care is common and guidelines indicate that patients with alarm symptoms, as defined by the urgent cancer referral guidelines, should be investigated by gastroscopy. The specificity and sensitivity of alarm symptoms is poor and only a small percentage of patients will turn out to have malignant disease. This primary care study shows that employing current guidelines will identify only 72% of patients at their initial visit to a general practitioner, but this figure could be increased to 86% if the guidelines included patients with weight loss or anaemia in the absence of dyspepsia. Past performance indicates that the majority of patients with the commonest symptom complex were not referred quickly and less than half were seen within 4 weeks.