Clostridium difficile (C. difficile) is a gram-positive, anaerobic bacterium that is one of the most common causes of colon infections in the United States. C. difficile is related to Clostridium tetani (causes tetanus) and Clostridium botulinum (causes botulism) all of which produce serious toxins. For the most part, C. difficile produces toxins known as Clostridium difficile toxin A (TcdA) and Clostridium difficile toxin B (TcdB). Toxin A and B are very similar to each other and essentially cause the same medical complications. C. difficile produces other toxins but A and B are most important. Toxins A and B cause damage to the intestinal mucosa (colon, large intestine) and generates inflammation of colon (colitis). In medical terms, A and B are potent enterotoxins.
The bacterium C. difficile comes in two forms. One form is an active form which is infectious but is not capable of surviving in the environment for long periods of time. The other form is an inactive form (so called noninfectious form) referred to as a spore that can survive in the environment for long periods of time. Although spores don’t cause infection directly, once they are ingested, or breathed in, can become active again and become infectious.
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Where is C. difficile Found
C. difficile is essentially found everywhere including water, air, soil, most surfaces as well as human and animal feces. C. difficile is often associated with medical facilities. This includes hospitals, nursing homes, extended care facilities and nurseries particularly for newborns. This bacterium is commonly found on toilet seats, bedpans, telephones, fingernails, jewelry, floors diaper pails, linens, telephones, stethoscopes and pets. This list is by no means exhaustive but gives you some idea of what to look for.
What is C. difficile Colitis
C. difficile is the most common nosocomial infection. Nosocomial refers to an infection that you acquired while in the hospital. It is antibiotic-linked form of colitis caused by C. difficile. That means it occurs in patients who have been using antibiotics. Just in the United States alone, they are more than three million C. difficile infections that occur each year. It is reported that 10 percent of patients will develop a C. difficile infection within one to two days of admittance.
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C. difficile’s Mechanism of Action
Recall that C. difficile comes in two forms: active and inactive forms. It turns out that C. difficile spores can occupy the colon in the dormant spore stage until a patient takes an antibiotic. At this point, the antibiotic disturbs normal flora (other bacteria living in the colon) and allows for C. difficile to convert to its infectious form and begin producing toxins that irritate the colon. This produces an influx of white blood cells to the colon. In severe cases, the toxins can destroy the colon lining causing tissue to break away. The tissue that has sloughed off the lining can mix with white blood cells and other damaged cells forming a pus which gives the lining of the colon a white patchy appearance (pseudomembranous colitis).
It is important to note that not everyone infected with C. difficile develops colitis. There are a number of individuals who are carriers (no symptoms) such as some adults, infants and children, however, they can pass C. difficile to others. It has been speculated that individuals who are carriers somehow have the ability to keep the bacteria in a non-active, noninfectious spore state or perhaps they may have developed antibodies to the toxins the bacteria produce. Nevertheless, their fecal matter will contain C. difficile.
C. difficile Colitis Symptoms
If you are experiencing mild to moderate C. difficile colitis, you may have a low-grade fever, mild diarrhea (for two days or more) with a mild form of stomach cramps and some tenderness.
If you are experiencing a severe C. difficile colitis, you may have high fever running somewhere between 102°F to 104°F along with a loss of appetite, nausea, weight loss that may lead to kidney failure. Expect to experience severe diarrhea 10 or more times a day with blood and severe stomach pain and tenderness. Keep in mind that severe diarrhea leads to dehydration and mineral (electrolyte) imbalances. Although severe colitis can lead to life-threatening issues, that is rare but not to be taken lightly.
When Should you see a Doctor?
If you are currently on antibiotics or have recently stopped your medication and experience a loose bowel three times (or more) a day for several days, contact your healthcare provider. Also, if you are experiencing a newly acquired fever, severe stomach pains/cramping or blood in your stool, contact your healthcare provider immediately.
Consequences of a C. difficile Infection
Given that you are experiencing severe diarrhea with blood and stomach cramping, this can lead to complications. The complications involve dehydration, kidney failure, toxic megacolon, perforated bowel and possible death.
Severe diarrhea will lead to a loss of fluids and minerals (dehydration) and this can cause blood pressure to drop to very low levels. If dehydration occurs rapidly, the kidneys can fail. In the case of toxic megacolon, your colon can’t expel stool and gas and becomes greatly distended which if left untreated may rupture allowing bacteria and toxins to enter your abdominal cavity (this is deadly). If you have serious damage to the large intestinal lining, it is possible to end up with a perforated bowel. Just as in megacolon, a perforated bowel can lead to bacteria passing into the abdominal cavity leading to peritonitis. If your condition is left untreated and you are experiencing kidney failure, megacolon or perforated bowel, even a moderate form of C. difficile can develop into a fatal disease.
How is C. difficile Diagnosed?
If you have recently taken antibiotics and developed diarrhea or if you develop diarrhea shortly after you have been admitted to the hospital, your doctor will suspect you have have C. difficile. There are a number of tests that can be done to detect C. difficile toxins in your stool. Several lab tests include enzyme immunoassay (EIA), polymerase chain reaction (PCR) and cell cytotoxicity assay. Some of these tests are not available everywhere and some can take a day or two to complete. Your doctor will determine what is best for you at the time.
Since some of the above tests are not necessarily definitive, your physician may decide to do a colon examination to confirm diagnosis. This makes use of a flexible tube with a small camera that can be placed inside the colon so the doctor can view areas of inflammation. If your physician is concerned about possible complications of your C. difficile infection, he/she may decide to do an abdominal X-ray or CT (computerized tomography) scan. The scans can detect things like bowel expansion, thickening of the colon wall or perforation through the gut lining.
C. difficile Treatment
The very first step in treating your C. difficile infection is to stop taking the antibiotic that brought about the infection if you haven’t already done so. There are two general treatments available depending on the severity of your infection which includes antibiotics or surgery.
The antibiotics keep C. difficile from proliferating which in turn gets the diarrhea and other complications under control. For mild cases, the antibiotic of choice is metronidazole (Flagyl). If you have moderate infection or a recurrent case, the antibiotic of choice is vancomycin (Vancocin). Another antibiotic is fidaxomicin. These antibiotics have different prices some of which are quite expensive as well as having different side effects. Again, your healthcare provider will determine what is best for you.
If you have a severe case of C. difficile which includes organ failure (kidney), severe pain or inflammation of the abdominal wall, chances are you will need to have diseased part of the colon removed to prevent further spread.
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