Pseudomembranous colitis

Pseudomembranous colitis - a particular type of diarrhea caused by Clostridium difficile, is usually associated with the use of antibiotics; acute inflammatory bowel disease caused by antibiotics, ranging from a mild short-term diarrhea to severe colitis, which is characterized by exudative plaque on the mucosa.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10],

Epidemiology

It accounts for 15-25% of cases of all diarrhea associated with the administration of antibiotics. The incidence of diarrhea associated with C. Difficile is 61 per 100 thousand people. Per year, in hospitals 12.2-13.0 per 10 thousand hospitalized patients, lethality is 0.6-1.5%.

Since C. Difficile is present in stool, any surfaces, devices or materials (bed, surface of bedside tables, bathtubs and shells, rectal thermometers) can be contaminated with patient discharges and serve as a reservoir of Clostridium difficile spores. Spores of Clostridium difficile spread from patient to patient through the hands of medical personnel who have previously contacted contaminated surfaces.

[11], [12], [13]

What causes pseudomembranous colitis?

Most often, pseudomembranous colitis develops under the influence of prolonged use of antibiotics ampicillin, lincomycin, clindamycin, cephalosporins, less often penicillin, erythromycin, levomycetin, tetracycline. Usually pseudomembranous colitis develops with oral administration of drugs, but it can also be the result of parenteral treatment with these drugs.

The pathogenesis of pseudomembranous colitis develops under the influence of prolonged use of antibiotics ampicillin, lincomycin, clindamycin, cephalosporins, less often - penicillin, erythromycin, levomycetin, tetracycline. Is that under the influence of antibiotic therapy there is an imbalance of normal intestinal flora, and anaerobic non-positive bacilliform bacteria Clostridium difficile, which produce toxins that damage the mucous membrane of the large intestine, multiply intensively.

With a mild form of the disease, there are mild inflammation and swelling of the mucous membrane of the large intestine. In a more severe course, the inflammation is very pronounced, possibly ulceration of the mucosa (sometimes it is difficult to distinguish the disease from ulcerative colitis in such cases).

With a pronounced lesion of the large intestine on the mucous membrane, convex, yellowish exudative plaques (pseudomembranes), consisting of fibrin, leukocytes, necrotic epithelial cells appear.

Pseudomembranous colitis - Causes

Symptoms of pseudomembranous colitis

Symptoms of pseudomembranous colitis appear during treatment with antibiotics, sometimes 1-10 days after the end of the course of treatment.

The main signs of the disease are:

• watery, and in severe cases, bloody diarrhea;
• pains in the abdominal cramping, localized mainly in the projection of the large intestine (usually in the region of the sigmoid colon);
• increase in body temperature to 38 ° C;
• symptoms of dehydration and significant electrolyte disorders (hypokalemia, hyponatremia, less often hypocalcemia), which is manifested by severe muscle weakness, paresthesia, cramps in the calf muscles.

In very severe cases, the development of toxic dilatation of the colon and even perforation.

Pseudomembranous colitis - Symptoms

Classification

• Carrying C. Difficile. Isolation of the causative agent from feces in the absence of clinical manifestations.
• Disease associated with Clostridium difficile. Clinical manifestations of infection in a patient whose feces excrete the pathogen or its toxins.
• Forms of the current: light, medium-heavy, heavy and life-threatening.
• Complications: pseudomembranous colitis, toxic megacolon, large intestine perforation, sepsis (extremely rare).

[14], [15], [16], [17], [18], [19], [20]

Diagnosis of pseudomembranous colitis

• General blood test: pronounced leukocytosis, shift of the leukocyte formula to the left, toxic granularity of neutrophils, increase in ESR.
• The general analysis of urine: without significant deviations from the norm, in severe cases moderate proteinuria is possible.
• Coprologic analysis: admixtures of blood in the feces, a large number of leukocytes, mucus, a positive reaction to soluble protein (Tribula reaction).
• Bacteriological analysis of feces. A characteristic picture of dysbiosis is revealed. To confirm the diagnosis, a stool culture is performed to identify Clostr. Difficile or analysis for the presence of an appropriate toxin. The toxin test is preferable (since it is technically very difficult to obtain a Clostr difficile culture) and is considered positive if a cytopathic toxin is identified (when tested on a tissue culture) neutralized by a specific antitoxin.

In healthy individuals, the frequency of carriage is Clostr. Difficile is 2-3%, the toxin is not detected.

• Endoscopic examination. For the most part, the pathological process is localized in the distal colon, so you can usually limit yourself to a sigmoidoscopy, with a more proximal and extensive lesion, a colonoscopy is performed. A characteristic endoscopic sign of the disease is the detection of pale yellow raids (pseudomembranes) on the inflamed mucosa of the large intestine (usually the rectus and sigmoid colon).

Irrigoscopy should not be performed because of the risk of perforation, especially in severe disease.

• Biochemical blood test: in case of severe disease it is possible to decrease the content of total protein, albumin, sodium, potassium, chlorides, calcium.

The diagnosis of pseudomembranous colitis is based on the history of the disease (association of the development of the disease with treatment with antibiotics), the presence of a colitis clinic, diarrhea with a blood impurity, the determination of Clostr toxins in the stool. Difficile, a characteristic endoscopic picture.

Pseudomembranous colitis - Diagnosis

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Treatment of pseudomembranous colitis

The first activity is the abolition of an antibiotic that provoked the development of pseudomembranous colitis. Already this one can, with mild forms, prevent the progression of the disease.

Etiotropic therapy consists in the appointment of antibacterial agents, to which C. Difficile is sensitive. This is vancomycin and metronidazole. Vancomycin is poorly absorbed in the intestine, with oral intake, its concentration is rapidly increasing. It is prescribed for 125 mg 4 times a day for 5-7 days. The drug of choice is metronidazole (0.25 3 times a day) for 7-10 days. In severe cases, when oral administration is difficult, metronidazole can be administered intravenously. It is also reported on the beneficial effect of bacitracin.

An extremely important pathogenetic therapy, especially in patients with severe forms of the disease. Its main directions are correction of water-electrolyte disorders and protein metabolism, restoration of the normal composition of the intestinal microflora, binding of toxin C.difficile.

With pronounced water-electrolyte disorders, therapy should be very intensive. In severe dehydration, which is often observed in patients with pseudomembranous colitis, the initial infusion rate in the first hour of treatment should be 8 ml / min / m2; then switch to infusion at a rate of 2 ml / min / m2. In fact, this means the introduction of up to 10-15 liters of fluid for 36-48 hours. Rehydration is carried out under the control of diuresis, the magnitude of CVP. Solutions like lactasol, solutions of Hartmann, Ringer are introduced. After the normalization of diuresis under the control of the ionogram, sodium chloride is introduced to eliminate hypokalemia. When violations of protein metabolism, plasma is poured, albumin. If dehydration is moderately expressed, oral rehydration with solutions such as a rehydron can be performed.

After improving the patient's condition, reducing diarrhea, and conducting a course (or courses) of etiotropic therapy, treatment with bacterial preparations for normalizing the intestinal biocoenosis is indicated. The course of treatment with one of the drugs should be 20-25 days, doses higher than with the treatment of the usual kind of dysbacteriosis: colibacterin 6-10 doses 2 times a day, bifidumbacterin and bifikol 10 doses 2 times a day.

To bind the toxin of clostridia in the intestine, the appointment of cholestyramine, colestipol is recommended. It seems that polyphepan can be useful. In severe complicated forms of pseudomembranous colitis, total colectomy is shown.

Pseudomembranous colitis - Treatment

Prevention of pseudomembranous colitis

Diarrhea caused by Clostridium difficile, a typical nosocomial infection, can cause an epidemic rise in morbidity in the hospital. The main preventive measure limiting the spread of infection is washing hands with soap or using alcohol-containing antiseptics. Hand treatment with chlorhexidine can significantly reduce the colonization of the hands of Clostridium difficlle and, therefore, prevent spreading. However, frequent washing can lead to dermatitis in the staff. The high effectiveness of the use of disposable gloves by hospital personnel to control the transmission of this infection has been proven. The re-use of gloves after treatment with alcohol-containing antiseptics that are effective against other spore-forming bacteria with respect to C. Difficile is significantly less effective, so this method should not be used.

Using PCR diagnostics, it has been proven that Clostridium difficile strains producing a toxin can spread rapidly from patient to patient if infection control methods are insufficient.

The main preventive measures of nosocomial spread of diseases:

• Rational use of antibiotics.
• Compliance with restrictive measures for patients with diagnosed or suspected disease caused by C. Difficile.
  • transfer of the patient to a separate ward or to the ward with other patients with the same diagnosis,
  • treatment of the hands of personnel with alcohol or water and soap (in the presence of an outbreak of infection, use only washing with soap and water before contact with patients, as rubbing alcohol is ineffective against spore-forming bacteria)
  • the use of gloves when working with patients inside the chambers,
  • use of special (separate) clothes (dressing gowns, hats),
  • maximum use of tools (to reduce direct contact),
  • continuation of all interventions until cessation of diarrhea

Treatment and disinfection of the environment:

• adequate washing and disinfection of surrounding surfaces and reusable devices, especially those that could be contaminated with secretions from the intestine and can be used by personnel,
• application of environmentally approved disinfectants based on hypochlorite for surface treatment after washing in accordance with the manufacturer's instructions (alcohol-based disinfectants are not effective against Clostridium difficile and should not be used for surface treatment)
• For the processing of endoscopes and other devices, use the manufacturer's instructions.

What prognosis does pseudomembranous colitis have?

With timely diagnosis, the abolition of antibiotics, which became the cause of the disease, is favorable. In case of severe complications in the form of dynamic intestinal obstruction, severe colitis, large intestine perforation and the need for surgical treatment in elderly patients with severe chronic diseases, the lethality with pseudomembranous colitis increases more than 30-fold.