Clostridium Difficile Infection CDI

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - John Hardy from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - John Hardy, Lucinda hampton, Reem Ramadan, Elaine Lonnemann, 127.0.0.1, WikiSysop, Oyemi Sillo, Kim Jackson, Vidya Acharya and Nupur Smit Shah  

Definition/Description

add text here

Prevalence

     C. Difficile is commonly a nosocomial pathogen found in a hospital or similar healthcare facility. Colonization rate of healthy adults is estimated to be 2% while the prevalence of hospitalized adults can be high as 40%. Nearly a third of all C. Difficile infections are community acquired which suggests a recent increase in non-nosocmial infections. Risk factors for the disease are: prolonged antibiotic use (>2 months), advanced age (>65), hospitalization, and residency in a long-term care facility. Prolonged antibiotic exposure is considered the most significant risk factor at this time. Several recent studies have identified patients taking proton pump inhibitors (PPI) are much more susceptible to colonization than those who are not. Asseri et al found patients taking PPIs were 3.6 times more likely to acquire a C. Difficile infection than those who were not. Although, some researchers theorize that acid suppression is not responsible for increased infection rate, but is a marker of other co-morbidities that increase risk of C. Difficile infection (CDI).
     As noted earlier prolonged antibiotic use and advanced age are two significant risk factors for CDI. Though prolonged antibiotic use seems to be most significant for initial infection, patients with advanced aged are most susceptible for disease reoccurrence. This increased infection and reoccurrence rate in the elderly is likely due to ineffective immune responses as well as insufficient recovery of commensal microbiota following treatment with anti-CDI antibiotics. Recurrent CDI typically occurs shortly after cessation of anit-CDI antibiotic pharmaceuticals with a reappearance of symptoms within 14-45 days. Reoccurance following anti-biotic therapy is primarily contributed to persistent alteration in gut flora of the patient. The causative strain of the CDI reoccurrence is molecularly identical to the original strain in many patients. First time reoccurrence rates have been documented as 33% and infection following previous reoccurrence as high as 45%.
     A trend of increasing CDI rates was reported throughout the United States in the early 2000’s. Various studies aimed to identify the cause of this significant increase in infection rate and were able to identify particularly strains that were associated with higher rates of infection. Specifically, BI/NAP1/027 strain was identified as a strain primarily responsible for the increased infection rate. This particular strain exhibited an increased resistance to antibiotics used to treat CDI and produced more than twenties times more toxin than historical strains. This strain is also associated with infection of people not previously considered at risk including young, seemingly healthy individuals not exposed to a healthcare environment or prolonged antibiotic treatment. There is also an increased mortality rate in patients infected with BI/NAP1/027 when compared to traditional strains, especially in people 60-90 years old.

Characteristics/Clinical Presentation

     Manifestations of CDI range from symptomless carriage, to mild-moderate diarrhea, to fatal pseudomembranous colitis. Fever, cramping, abdominal discomfort, and peripheral leukcytosis are common though found in less than half of patients with CDI. The passage of musucs, melena, or hematochezia are rare. Non-GI related symptoms such as arthritis and bacteremia have very rarely been reported in the literature. Patients who have undergone a complete colectomy have been reported to develop C. Difficile ileitis or puchitis in rare instances. Severe CDI can cause: dehydration, electrolyte disturbances, hypoalbuminemia, toxic megacolon, bowel perforation, hypotension, renal failure, sepsis, clonic ileus, toxic dilatation, systemic inflammatory response syndrome, and death. Patients presenting with unexplained leukocytosis should alarm the clinician and prompt them to request stool samples sent for diagnostic testing.

Associated Co-morbidities

     Co-morbidities such as cancer, old age, and renal disease were significantly correlated with a higher rate of mortality from CDI in an English Cohort study of over 2,000 people . Other significant risk factors mentioned in previous sections including: inflammatory bowel disease, immunocompromise, chemotherapy, abdominal surgery, gastrointestinal procedure, previous C. Difficile infection.

Medications

add text here

Diagnostic Tests/Lab Tests/Lab Values

add text here

Etiology/Causes

add text here

Systemic Involvement

add text here

Medical Management (current best evidence)

add text here

Physical Therapy Management (current best evidence)

add text here

Alternative/Holistic Management (current best evidence)

add text here

Differential Diagnosis

add text here

Case Reports/ Case Studies

add links to case studies here (case studies should be added on new pages using the case study template)

Resources

add appropriate resources here

Recent Related Research (from Pubmed)

see tutorial on Adding PubMed Feed

References

see adding references tutorial.