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Episode 77: A 78-Year-Old with Diarrhea
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Episode 77: A 78-Year-Old with Diarrhea
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T00H05M58S
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https://cadmoreoriginalmedia.blob.core.windows.net/ac7a3884-7e58-464d-9ee1-8e3a83fe287a/Harrisons Podclass- Episode_77 with tag.mp3?sv=2019-02-02&sr=c&sig=TTQKu4kDja77ePG63gcyyLvATDj4i8fDBkHttgT0BRk%3D&st=2024-05-03T18%3A10%3A32Z&se=2024-05-03T20%3A15%3A32Z&sp=r
Upload Date:
2022-11-22T00:00:00.0000000
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Language: EN.
Segment:0 .
[upbeat intro music] [Dr. Handy] Hi, welcome to Harrison's Podclass, where we discuss important concepts in internal medicine. I'm Cathy Handy. [Dr. Wiener] And I'm Charlie Wiener, and we're coming to you from the Johns Hopkins School of Medicine. Welcome back to Harrison's Podclass. Today's case is a 78-year-old with diarrhea. So Cathy, a 78-year-old woman presents to the hospital from her nursing home with complaints of diarrhea.
[Dr. Handy] I'm going to say this is C. diff. [Dr. Wiener chuckles] Huh! Yeah, exactly it is. C. difficile infection is a huge issue, so it's good to be discussing it. I'd also like to give tribute to a true Hopkins icon, Dr. John Bartlett, whose work was instrumental in describing C. difficile colitis. He unfortunately passed away early in 2021. [Dr. Handy] Yeah, big shout-out to Dr. Bartlett.
Just to give some background, C. difficile is an obligate anaerobe Gram-positive bacterium that may cause infection in association with antimicrobial use and the consequent disruption of the normal colonic microbiota. It causes the most commonly diagnosed diarrheal illness acquired in the hospital and results from the fecal-oral route, a.k.a. ingestion of C. diff spores that secrete toxins causing diarrhea, and in the most severe cases, pseudomembranous colitis.
Let's get back to the patient. So start with the history, and was she taking any antibiotics? Because that's one of the big risk factors. [Dr. Wiener] Yeah, well, six months ago she was actually treated with oral metronidazole for a documented C. difficile infection. And she was recently again treated with ceftriaxone for pyelonephritis due to E. coli. [Dr. Handy] And what's her clinical presentation like now?
[Dr. Wiener] On presentation from the nursing home to the hospital she appears uncomfortable and has a temperature of 38.4 centigrade. Her blood pressure is 96/60 and her heart rate is 115 per minute. Her abdomen is distended and tympanitic with diffuse tenderness to palpation. An abdominal X-ray shows distention of the colon with ileus.
Initial lab exams show white blood cell count of 27.2 with 92% neutrophils and 3% band forms. Her hemoglobin is 9.2 and her hematocrit is 28%. One month ago, her hemoglobin was 10.1. Given her recent antibiotic use, you consider, as we've discussed, C. difficile infection. So the question's going to be about the clinical findings. And the question reads, which of the following findings is most unlikely to be found in C. difficile infection?
And the options are A. bloody diarrhea; B. fever; C. ileus; D. leukocytosis; or E. recurrence after therapy. [Dr. Handy] Well, let's first say that I'm quite worried about this patient because she's febrile, tachycardic, hypotensive, and her abdomen sounds toxic. [Dr. Wiener] We'll talk more about that later.
Again, let's refer and go back to the clinical manifestations of C. difficile infection. [Dr. Handy] Overall, diarrhea is the most common manifestation, but the stools are almost never grossly bloody. They are typically soft and unformed to watery or mucoid. Now, urban legend is that the stool has a characteristic odor, but that hasn't stood up to rigorous scrutiny. [Dr. Wiener] Okay, so the answer to the first question is A. bloody stools are the most unlikely.
But what about the other clinical manifestations listed in the question? [Dr. Handy] Well, fever is present in 28% of cases, abdominal pain in 22% of cases, and leukocytosis in 50%. The diagnosis can be frequently overlooked with adynamic ileus, which results in cessation of stool passage, and that's seen on X-ray in about 20% of cases. So, remember that not all C. difficile infection has diarrhea.
[Dr. Wiener] What about an elevated white cell count? [Dr. Handy] Yeah, that's often a clue, and an unexplained leukocytosis should make you think of C. difficile in a patient at risk. Patients with white blood cell counts over 15,000 are at high risk for complications, particularly toxic megacolon and sepsis. [Dr. Wiener] Okay, that leaves recurrence after therapy as a concern.
[Dr. Handy] Yes, so C. diff diarrhea recurs after treatment in about 15 to 30% of cases. Susceptibility to recurrence of clinical C. diff infection is likely a result of continued disruption of the normal fecal microbiota caused by the antibiotic used to treat C. diff infection. [Dr. Wiener] And in this case, she got another dose of ceftriaxone, so that probably put her at an even - higher risk, right? - [Dr. Handy] Yeah.
[Dr. Wiener] Okay, so you mentioned that you think this patient is toxic, how would you treat her? [Dr. Handy] In addition to supportive care, so managing the blood pressure, fluid resuscitation, I'd also start antibiotics. These patients are very difficult to treat medically because of the difficulty delivering oral medications to a patient with ileus. So in these cases, we will give IV and oral medications.
Now, IV metronidazole would be the treatment of choice and you'd combine that with oral vancomycin. Studies have shown that oral vancomycin is likely more effective than oral metronidazole. And two large clinical trials comparing oral vancomycin and fidaxomicin indicated comparable clinical resolution of diarrhea in about 90% of patients, and the rate of recurrent C. diff infection was significantly lower with fidaxomicin.
So initial therapy for non-fulminant cases of C. difficile infection should be treated with oral vancomycin or fidaxomicin. [Dr. Wiener] So we really should not be using oral metronidazole as a first-line therapy any longer? [Dr. Handy] Correct. [Dr. Wiener] Okay, so great. So the teaching points in this case are that C. difficile infection can present with a fulminant illness where the patient may appear septic with an acute abdomen.
In these cases, a combination of IV and oral therapy is indicated, but the patient should be monitored closely for the need of surgery. Oral fidaxomicin or oral vancomycin are the best choices for initial therapy for patients with less severe disease. [Dr. Handy] And you can read more about this in Harrison's chapter on C. diff. [outro music] [Mr. Shanahan] This is Jim Shanahan, publisher at McGraw Hill.
Harrison's Podclass is brought to you by McGraw Hill's Access Medicine, the online medical resource that delivers the latest trusted content from the best minds in medicine. Go to accessmedicine.com to learn more.