Clostridium colitis: challenges in diagnosis and treatment

Background: Clostridium difficile infection (CDI) has been reported to occur with increasing frequency and with more severe presentations being encountered. This article presents data from The Alfred Hospital highlighting the increased incidence, the increased severity and the broader clinical presentations observed. A case series highlights a variety of clinical scenarios that provided diagnostic and management challenges. We additionally describe a novel form of treatment for fulminant colitis. Methods: A retrospective review of C. difficile toxin (CDT)-positive and culture-positive cases was performed at The Alfred Hospital (2010-2012). Six cases are then presented as a case series to highlight the broad and atypical types of presentations one may encounter. Finally, a novel method for managing fulminant colitis operatively is presented. Results: A fourfold increase in cases of toxin-positive and culture-positive cases was noted over the initial 14 months of the period of analysis, the rate of cases detected then plateaued. This increase could not be explained by increased testing being undertaken. It is also not associated with increased usage of antibiotics nor with increased patient numbers being treated. Conclusion: CDI can present in various clinical forms. In our hospital, the number of cases of toxin-positive and culture-positive detection is increasing. A low threshold is required to identify and adequately treat patients with CDI. Fulminant colitis can be managed successfully with the creation of a diverting loop ileostomy, colonic washout and subsequent antegrade colonic vancomycin enemas.