CICM SAQ 2012.1 Q3

Questions

a) List the patient-related risk factors associated with the development of Clostridium difficile enterocolitis
b) List two tests that can be used for diagnosis of Clostridium difficile enterocolitis.
c) List four markers of severity of disease in Clostridium difficile enterocolitis
d) What are other possible causes of infective diarrhoea in the critically ill?

Answers

Answer and interpretation

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
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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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