Pseudomembranous colitis

Pseudomembranous colitis is a specific type of diarrhea caused by Clostridium difficile, usually associated with antibiotic use; an acute inflammatory disease of the colon associated with antibiotics, ranging from mild, short-term diarrhea to severe colitis characterized by exudative plaques on the mucosa.

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Epidemiology

It accounts for 15-25% of all diarrhea cases associated with antibiotic prescription. 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 fall ill, the mortality rate is 0.6-1.5%.

Because C. difficile is present in feces, any surface, device, or material (bed, nightstand surfaces, bathtubs, sinks, rectal thermometers) can become contaminated with patient excreta and serve as a reservoir for Clostridium difficile spores. Clostridium difficile spores are spread from patient to patient via the hands of health care personnel who have previously come into contact with a contaminated surface.

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What causes pseudomembranous colitis?

Most often, pseudomembranous colitis develops under the influence of long-term use of antibiotics ampicillin, lincomycin, clindamycin, cephalosporins, less often - penicillin, erythromycin, chloramphenicol, tetracycline. Usually pseudomembranous colitis develops with oral use of drugs, but can also be the result of parenteral treatment with the above drugs.

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

In a mild form of the disease, there is mild inflammation and swelling of the mucous membrane of the large intestine; in a more severe form, the inflammation is quite pronounced, and ulceration of the mucous membrane is possible (sometimes in such cases, the disease is difficult to distinguish from nonspecific ulcerative colitis).

In case of severe damage to the large intestine, convex, yellowish exudative plaques (pseudomembranes) appear on the mucous membrane, consisting of fibrin, leukocytes, and necrotic epithelial cells.

Pseudomembranous Colitis - Causes

Symptoms of pseudomembranous colitis

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

The main symptoms of the disease are:

• watery, and in severe cases bloody diarrhea;
• abdominal pain of a cramping nature, localized mainly in the projection of the large intestine (usually in the area of the sigmoid colon);
• increase in body temperature to 38°C;
• symptoms of dehydration and significant electrolyte disturbances (hypokalemia, hyponatremia, less commonly hypocalcemia), which manifests itself as severe muscle weakness, paresthesia, and cramps in the calf muscles.

In very severe cases, toxic dilation of the colon and even perforation may develop.

Pseudomembranous Colitis - Symptoms

Classification

• Carriage of C. difficile. Isolation of the pathogen from feces in the absence of clinical manifestations.
• Clostridium difficile-associated disease. Clinical manifestations of infection in a patient whose stool contains the pathogen or its toxins.
• Forms of the disease: mild, moderate, severe and life-threatening.
• Complications: pseudomembranous colitis, toxic megacolon, colon perforation, sepsis (extremely rare).

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Diagnosis of pseudomembranous colitis

• Complete blood count: pronounced leukocytosis, left shift in leukocyte count, toxic granularity of neutrophils, increased ESR.
• General urine analysis: no significant deviations from the norm, in severe cases moderate proteinuria is possible.
• Coprological analysis: blood in the stool, a large number of leukocytes, mucus, a positive reaction to soluble protein (Triboulet reaction).
• Bacteriological analysis of feces. A characteristic picture of dysbacteriosis is revealed. To confirm the diagnosis, a stool culture is performed to detect Clostr. difficile or an analysis is performed to detect the presence of the corresponding toxin. A test for the toxin is preferable (since it is technically very difficult to obtain a Clostr. difficile culture) and is considered positive if a cytopathic toxin is identified (during a tissue culture study) that is neutralized by a specific antitoxin.

In healthy individuals, the carriage rate of Clostridium difficile is 2-3%, and the toxin is not detected.

• Endoscopic examination. Most often, the pathological process is localized in the distal part of the colon, so usually a rectoscopy can be enough; in case of a more proximal and extensive lesion, a colonoscopy is performed. A characteristic endoscopic sign of the disease is the detection of pale yellow plaque (pseudomembranes) on the inflamed mucous membrane of the colon (usually the rectum and sigmoid colon).

Irrigoscopy should not be performed due to the risk of perforation, especially in severe cases of the disease.

• Biochemical blood test: in severe cases of the disease, a decrease in the content of total protein, albumin, sodium, potassium, chlorides, and calcium is possible.

The diagnosis of pseudomembranous colitis is made on the basis of anamnesis data (the relationship between the development of the disease and antibiotic treatment), the presence of clinical colitis, diarrhea with blood, the detection of Clostridium difficile toxins in the feces, and a characteristic endoscopic picture.

Pseudomembranous Colitis - Diagnosis

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Treatment of pseudomembranous colitis

The first step is to stop the antibiotic that triggered pseudomembranous colitis. This alone can prevent the disease from progressing in mild forms.

Etiotropic therapy consists of prescribing antibacterial agents to which C. difficile is sensitive. These are vancomycin and metronidazole. Vancomycin is poorly absorbed in the intestine; when taken orally, its concentration increases rapidly. It is prescribed at 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. A favorable effect of bacitracin is also reported.

Pathogenetic therapy is extremely important, 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 intestinal microflora, and binding of the C.difficile toxin.

In case of severe water-electrolyte disorders, therapy should be very intensive. In case of 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 an infusion rate of 2 ml/min/m2. In fact, this means the introduction of up to 10-15 liters of fluid over 36-48 hours. Rehydration is carried out under the control of diuresis, the value of the central venous pressure. Solutions such as lactasol, Hartmann's, Ringer's solutions are administered. After normalization of diuresis, sodium chloride is administered under the control of an ionogram to eliminate hypokalemia. In case of protein metabolism disorders, plasma and albumin are transfused. If dehydration is moderate, rehydration can be carried out orally with solutions such as rehydron.

After the patient's condition has improved, diarrhea has decreased, and a course (or courses) of etiotropic therapy has been completed, treatment with bacterial preparations is indicated to normalize the intestinal biocenosis. The course of treatment with one of the preparations should be 20-25 days, the doses should be higher than in the treatment of the usual type of dysbacteriosis: colibacterin 6-10 doses 2 times a day, bifidumbacterin and bificol 10 doses 2 times a day.

In order to bind the clostridial toxin in the intestine, it is recommended to prescribe cholestyramine and colestipol. Polyphepan may apparently be useful. In severe complicated forms of pseudomembranous colitis, total colectomy is indicated.

Pseudomembranous Colitis - Treatment

Prevention of pseudomembranous colitis

Clostridium difficile-associated diarrhea is a typical hospital-acquired infection that can cause an epidemic increase in hospital morbidity. The main preventive measure limiting the spread of infection is hand washing with soap or the use of alcohol-based antiseptics. Hand treatment with chlorhexidine can significantly reduce the colonization of hands with Clostridium difficile and, therefore, prevent its spread. However, frequent hand washing can lead to dermatitis in personnel. The use of disposable gloves by healthcare personnel has been proven to be highly effective in controlling the transmission of this infection. Reuse of gloves after treatment with alcohol-based antiseptics, which are effective against other spore-forming bacteria, is significantly less effective against C. difficile, so this method should not be used.

PCR diagnostics have shown that toxin-producing strains of Clostridium difficile can spread rapidly from patient to patient if infection control methods are inadequate.

The main preventive measures against nosocomial spread of diseases:

• Rational use of antibiotics.
• Compliance with restrictive measures for patients diagnosed or suspected of having a disease caused by C. difficile.
  • transferring the patient to a separate room or to a room with other patients with the same diagnosis,
  • treating the hands of staff with alcohol or soap and water (if there is an outbreak of infection, use only washing with soap and water before contact with patients, since rubbing with alcohol is ineffective against spore-forming bacteria),
  • use of gloves when working with patients inside wards,
  • use of special (separate) clothing (robes, caps),
  • maximum use of tools (to reduce direct contact),
  • continue all measures until diarrhea stops

Environmental treatment and disinfection:

• adequate cleaning and disinfection of surrounding surfaces and reusable equipment, especially those that may have been contaminated with intestinal secretions and may be used by staff,
• use of approved hypochlorite-based disinfectants for environmental treatment of surfaces 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 processing endoscopes and other devices, follow the manufacturers' instructions.

What is the prognosis for pseudomembranous colitis?

With timely diagnosis, cancellation of antibiotics that caused the disease - favorable. In the event of severe complications in the form of dynamic intestinal obstruction, severe colitis, perforation of the colon and the need for surgical treatment in elderly patients with severe chronic diseases, the mortality rate in pseudomembranous colitis increases more than 30 times.