Question

You are on a clinical rotation at a local hospital and are shadowing Nurses and hanging out at the nursing station. One of the nurses who had just came out of the restroom from his third or forth trip to the restroom collapsed at his desk. He has been looking very pale and has been losing weight. You run to get the attending physician. The physician took one look and said something that sounded like "see dif" to the nursing instructor. She said he has been taking antibiotics for a nasty sinus infection. You are asked to prepare a written report on his condition, but are afraid to ask what it is. Where do you look first? What is it? How is it spread? Why is it hard to kill? Who is most affected by it?

Answer 1

From the presenting case study, following observations can be made:

• The subject in the given case study is Male, very pale and losing weight
• Very pale represents the low blood pressure
• Third or fourth trip to the rest room represents diarrhea
• Fainting could be attributed to dehydration due to frequent diarrhea that made him unconscious
• "See dif" said by physician could actually mean short for C.difficile (Clostridium difficile infection) which exactly coincides with the patient presentation
• "Taking antibiotics" for sinus infection could have killed the normal flora in the intestine making the subject vulnerable for the opportunistic C. difficile infection
• Being nurse by profession and since normal disinfectants cannot completely disinfect C.difficile that may be present in the hospital setting could have made its way to the subject as he is more vulnerable due to immuno-compromise conferred by the antibiotics

Where do you look first?

• Looking for the blood or mucus in the stools
• If access has been granted for blood tests, looking for increased leucocyte count (20-40000 cells) could give an idea about the disease
• Enzyme immunoassays, endoscopy which reveals pseudomembranous colitis, increased serum creatinine could confirm the diagnosis of C. difficile infection

What is it ?

• From the above observations, it can be concluded that it is Clostridium difficile infection. C. difficile is a gram positive bacteria which causes opportunistic infections. The normal flora suppresses the growth of this organism but its growth is increased when there is a vacuum of normal flora by antibiotics (as seen in this case) which makes the subject vulnerable to the infection. Symptoms include fever, diarrhea with blood and mucus in stools, increased white blood cell count, pseudomembranous colitis, hypotension, electrolyte imbalance.

Why is it hard to kill?

• Clostridium difficile is a spore forming anaerobic bacteria which can survive outside the host for longer periods of time. They are generally not killed by most of the disinfectants (which usually contain alcohol) due to the tough nature of the spore shell.
• These spores reach the susceptible and vulnerable hosts like immunocompromised, elderly or younger populations, subjects under rigorous antibiotic treatment or surgical procedures through oro-fecal route
• The spores survive the gastric HCl and reaches the intestine where the organisms invade the host cells resulting in symptoms

Who is most affected by it ?

The most affected populations are:

• Immunocompromised subjects like those having chronic illness, malnourished
• Elderly population
• Younger children
• Patients taking antibiotics that wipe off the intestinal flora
• Patients in hospital setting where C.difficile is prevalent and proper disinfection is not practised
• Patients under serious medical procedures due to compromise in the natural line of defenses