CICM SAQ 2012.1 Q3

a) List the patient-related risk factors associated with the development of Clostridium difficile enterocolitis

• Broad spectrum antibiotics in particular clindamycin, quinolones, amoxycillin, cephalosporins
• Immunosuppressive therapy /Cytotoxic chemotherapy
• Gastric acid suppression
• Age>65
• Prolonged hospitalisation
• Renal impairment
• Prior GI surgery

b) List two tests that can be used for diagnosis of Clostridium difficile enterocolitis.

• Faecal culture determination of the toxigenic status of the infecting C. difficile isolate
• Screening EIA to detect C. difficile glutamate dehydrogenase (GDH)
• EIAs to detect toxins A and/or B
• Cell culture cytotoxicity assays that directly detect stool cytotoxic activity
• PCR-based assays to detect conserved gene targets within the pathogenicity locus of C. difficile

c) List four markers of severity of disease in Clostridium difficile enterocolitis

Clinical

• Fever (> 38.5°C), rigors
• Haemodynamic instability
• Peritonitis or evidence of bowel perforation Ileus or toxic megacolon

Laboratory

• White blood cell count >15 × 109/L and < 20% neutrophils
• Elevated lactate level
• Rise in creatinine level (> 50% above baseline)
• Albumin level < 25 mg/L

Other investigations

• Large intestine distension, colonic wall thickening, fat stranding, unexplained ascites (imaging)
• Pseudomembranous colitis (colonoscopy)

d) What are other possible causes of infective diarrhoea in the critically ill?

• Viruses –Norovirus, adenovirus, CMV (rotavirus in children)
• Bacterial pathogens – Campylobacter, E.Coli, cholera, salmonella
• Protozoa – Cryptosporidium, Giardia
• Parasitic -Strongyloides