Introduction to Pseudomembranous Colitis/ Difficile Colitis:
Pseudomembranous Colitis, also known as C-Diff Colitis, C-Difficile Colitis, Necrotizing Colitis, or Antibiotic-Associated Colitis, is a condition of inflammation of the Colon associated with an overgrowth of the “bacterium Clostridioides difficile” or “Clostridium Difficile”. C-Diff causes severe diarrhea and colitis. Colitis is an inflammation of the Colon (large intestine).
The overgrowth of C. difficile is usually caused by antibiotics especially the orally administered ones and a long stay at the hospital. C Difficile occurs because antibiotics change the large intestinal bacteria thus allowing the C Difficile Bacteria to over-grow and produce its toxin. Pseudomembranous Colitis is common in patients older than 60 years.
Pseudomembranous Colitis Symptoms:
Usually, Pseudomembranous Colitis appears with the following signs and symptoms;
- Watery Diarrhea
- Loss of appetite
- Abdominal pain, cramps, and tenderness
- Colon Colitis (Inflammation in the Large Intestine)
- A large amount of mucous and puss in stools
- Mild to moderate fever
- Nausea and sometimes vomiting
- Dehydration due to persistent watery diarrhea
- In greater virulence, sepsis can occur. Sepsis is the body’s potentially dangerous overreaction to infection
- Pseudomembranous Colitis starts within one or two days of starting taking antibiotics
- It may last for a few days to months even after stopping taking antibiotics
Causes of Pseudomembranous Colitis:
Usually, the Colon (large intestine) contains a number of different types of bacteria, which are present in a healthy balance. There are some health-friendly as well as toxic bacteria in the Colon. The health-friendly bacteria generally check and limit the overgrowth of toxic bacteria and their activities. This balance is disrupted by the use of antibiotics, thus resulting in the overgrowth of the C-Difficile bacterium, which is infectious in nature. The production of toxins made by C Difficile rises to a high level, which damages the large intestine and results in severe diarrhea, inflammation, pain, and dehydration.
As the use of antibiotics causes pseudomembranous colitis, we need to point out those antibiotic medicines, which generally cause this condition. These medicines/ drugs include;
- Fluoroquinolones: The fluoroquinolones currently available in the United States include ciprofloxacin, gemifloxacin, levofloxacin, moxifloxacin, norfloxacin, and ofloxacin. These agents are well absorbed orally and well tolerated with a low rate of adverse effects. Among these drugs, Ciprofloxacin and levofloxacin are known to cause Difficile Colitis.
- Penicillins: Penicillins like amoxicillin, ampicillin, augmentin, Unasyn, Dicloxacillin Sodium, etc cause Difficile Colitis.
- Clindamycin: Clindamycin also known as Cleocin is used to treat certain types of bacterial infections, including infections of the lungs, skin, blood, female reproductive organs, and internal organs. Use of Cleocin may cause an overgrowth of C Difficile bacterium in the Colon.
- Cephalosporins: Cephalosporins are a large group of antibiotics that belong to a class known as beta-lactams. These drugs are used to treat bacterial infections including Ear infections, Pneumonia, and other upper respiratory tract infections. Cephalosporins like such as cefixime (Suprax) may allow C Difficile to overgrow and cause Colitis.
Risk Factors of Pseudomembranous Colitis:
- Antibiotics: Pseudomembranous Colitis is caused by an overgrowth of C Difficile bacterium because of the use of antibiotics. Therefore the primordial risk factor is the use of antibiotics itself.
- Long Stay in Hospital/Nursing Homes: Staying in Hospital or nursing home is another risk factor because the lack of sanitary procedures, cleanliness, hand washing, and other hygienic measures increases the transmission rates of C. difficile. In order to prevent this disease to transmit from one patient to another, the nursing staff must regularly wash their hands and follow sanitary procedures.
- Age Factor: Patients with ages more than 60, and 65 years, are more vulnerable to C-Diff.
- Weak Immune System: Persons with a weak immune system may easily fall prey to C-Difficile.
- Other Colon Diseases: Patients already having colon diseases, like Inflammatory bowel disease or Colorectal Cancer, Colonic Polyps, Ulcerative colitis, Diverticulitis, etc may increase the risk of Pseudomembranous Colitis, while taking antibiotics.
- Recent Intestinal Surgery: Intestinal surgery is also known as Colorectal surgery. Colorectal surgery increases the risk of Clostridium difficile (Bacterium) infection. C Diff is an increasingly common nosocomial (originating in hospital) occurrence, with a reported general incidence of up to 7.8%, while its incidence in patients undergoing colorectal surgery is almost three times higher.
- Chemotherapic Treatment of Cancers: Chemotherapy may disrupt the balance of the gut microbiome, and causes mucositis, which may render germination of C. difficile spores more prevalent, leading to greater virulence.
Pathological Tests and Examination to Diagnose C Difficile:
In order to diagnose the condition precisely, the following tests are of great importance:
Colonoscopy or flexible sigmoidoscopy:
It is a procedure in which a thin flexible fiber-optical tube with a light on its tip, and end with a camera device is inserted through the anal opening to examine the colon. A Doctor examines the entire colon and rectum by Colonoscopy, whereas a Sigmoidoscopy is only used to examine the lower part of the large intestine and rectum. These tests allow examining the part of the colon with inflammation, which indicates C.Difficile Infection. Pathologist/ Doctor also gets tissue samples for further tests through this process
Immunoassay for C difficile toxin in the stool:
Immunoassay is a sandwich enzyme (ELISA) that was developed to detect Clostridium difficile toxins A and B in the stools of patients with antibiotic-associated diarrhea and colitis.
The simplest way to diagnose C. Diff Colitis is the stool test, in which you provide a stool sample to a pathologist to determine whether the sample has signs of C. difficile. Newer Stool tests like Polymerase chain reaction (PCR) tests are a fast, highly accurate way to diagnose certain infectious diseases and genetic changes.
A high level of white blood cells is a sign of infection. Very high levels can signify a more severe C. difficile infection. In such conditions, a person may have frequent watery diarrhea, intense stomach cramps, and dehydration.
Computed Tomographic Scan (CT Scan) is widely used in the field of pathology. Pathologists use X-rays and a computer to create three-dimensional, cross-sectional images of the body. If a doctor suspects you have a C.Diff infection, they will examine the intestine through a CT scan. Your doctor may give you a contrast agent before the scan to enhance the images. It can be taken by mouth or as an injection into a vein.
The severity of the Condition and Time to See a Doctor:
Contact your physician/ doctor right away if you have the following signs of complications:
- Any bloody stools (especially after taking antibiotics)
- Five or more episodes of diarrhea per day, and persistence for more than a day
- Severe abdominal pain and cramp
- Signs of dehydration
Mediums for Transmission of the Disease:
Most cases of C.Difficile Colitis cases are found in people who stayed in hospitals, and nursing homes under healthcare services. In healthcare centers including hospitals, nursing homes, and long-term care facilities, where germs spread easily, the use of antibiotics is common, which makes people vulnerable to infection. C. Difficile spreads by;
- Hands of patients, caregivers, and doctors
- Handles of carts, chairs, wheelchairs, etc
- Bedrails, tables, statchers, chairs, bedside tables
- Toilets, wash basins and sinks
- Medical devices like stethoscopes, thermometers, microscopes, lab equipment, and other machines
- Telephones, Bells, remote controls, and other electronic devices, which are frequently touched by various people
- Emergency vans, and vehicles.
Complications Associated with Pseudomembranous Colitis:
If C.Difficile Colitis is not timely cured, it may lead to the following complicated conditions:
Severe loss of body fluid and electrolytes will occur as a result of diarrhea. Loss of fluid and electrolytes is known as dehydration, which weakens the body to function normally. As a result, the blood pressure may also drop to an alarming level. Low blood pressure for a long time can put a life in danger.
Our kidneys remove wastes and extra fluid from our bodies. Kidneys also remove acid that is produced by the cells of our body and maintain a healthy balance of water, salts, and minerals such as sodium, calcium, phosphorus, and potassium in the blood. This whole process is possible only through a balance between water and minerals in cells and blood. Diarrhea results in dehydration leading to an extraordinary excess quantity of salts and minerals in the blood. Sometimes dehydration occurs so quickly that kidney functions rapidly deteriorate. The deteriorated condition of the kidney is known as “Kidney Failure”.
Megacolon means an extralarge-sized colon. Normally the process of peristalsis helps undigested food and water expel out through the rectum and anal opening. In this rare condition of C-Difficile, your colon is unable to expel gas and stool, causing it to become greatly enlarged (megacolon). If not timely treated, the Colon may rupture. The toxic bacteria enter your abdominal cavity and then your bloodstream. The toxicity of the bacteria will be life-threatening on all accounts.
Bowel Perforation/ Rupture in Colon:
The C-Difficile Bacterium acts on the inner lining of the Colon and causes extensive damage to the lining of the colon. In extreme conditions, when the colon is unable to expel the gases and stool, it gets enlarged and intoxicated. The enlarged colon is known as Megacolon, which is finally ruptured/perforated. Bacteria spilling from the perforated colon into your abdominal cavity can lead to a life-threatening infection (peritonitis).
A mild to moderate C-Difficile in rare cases (if persisted for a long time) and a serious C-Difficile infection in common cases can quickly proceed to fatality if not treated promptly.
Patients, their friends, family members, and health service providers should take strict hygiene initiatives, and follow infection control guidelines in hospitals and nursing homes. Some important preventive and pre-emptive measures to check the infection spread are as follows;
Avoid unnecessary and excessive use of antibiotics.
Antibiotics are often used unnecessarily to treat viral infections, which is quite unhelpful. Viral infections are never treated with antibiotic drugs. Antibiotic drugs are useful only to kill bacteria. The unnecessary use of antibiotics will kill healthy bacteria present in the Colon. For example, some physicians prescribe antibiotics to patients with measles with the intention to relieve the patient. Though measles is a viral disease, there is no specific drug discovered to treat measles. Moreover, antibiotics are also used for a long time to treat bacterial diseases. The excessive use of antibiotics is harmful as well.
Healthcare givers should take hygienic measures before and after treating each person in their care. In case of a C-difficile outbreak, using antiseptic soap, non-alcoholic hand sanitizer, and warm water is a better choice for hand hygiene, An alcoholic hand sanitizer would not be an adequate choice because it doesn’t effectively destroy C-difficile spores. Visitors from the outdoors also follow these guidelines. Sanitary workers should wear disposable gloves and isolation gowns while cleaning the patient’s room.
People who are suffering from C-Difficile should have a separate room or only share with those who have the same illness. Healthcare givers should not touch the bedrails, bedside tables, and chairs, used by the patient. If so happened, wash their hands before and after providing service.
Use of Antiseptic Cleaning Agents.
C-Difficile Bacterium is resistant to routine cleaning products. Cleaning agents containing chlorine bleach should be used to disinfect the surfaces. Apart from the case of C-Difficile, these measures should be taken in all types of healthcare setups.